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ON 



EPIDEMICS 



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BY 

FRANCIS EDMUND ANSTIE, M.D., F.R.C.P. 

Senior Assistant Physician to the Westminster Hospital. 



FIRST AMERICAN EDITION. 



PHILADELPHIA: 

J. B. LIPPOCOTT & CO. 

1866. 



^ 



<v 



Entered, according to Act of Congress, in the year 1866, by 

J. B. LIPPINCOTT & CO., 

In the Clerk's Office of the District Conrt of the United States for the 

Eastern District of Pennsylvania. 



INTRODUCTION. 



A book such as Br. Anstie's little volume, 
which is uow presented to the American public, 
has long been a desideratum. Written as it is 
by one distinguished for his scientific acquire- 
ments, it cannot fail to be of great service to the 
people wherever it is circulated. Medical men 
have been charged with a reluctance to instruct 
the great mass of mankind in those truths which 
are capable of being understood and acted upon 
by all intelligent and moderately educated per- 
sons. "Without admitting the full force of this 
allegation, there is no doubt that if the great 
men of the profession had written more for the 
people than they have, quackery would not be 
so rampant and wide-spread as it is at present. 
In the belief that our people will gladly re- 

(iii) 



IV INTRODUCTION. 



ceive instruction in the important matters con- 
tained in the present volume, it is submitted for 
their consideration and guidance at a time when 
the knowledge it contains will prove more than 
ordinarily useful. 

WM. A. HAMMOND, M.D. 

New York, August 17th, 1866. 



PREFACE. 



The following short treatise is an expansion of an 
article which appeared in the January number of the 
British Quarterly Review, and I have naturally ex- 
perienced some difficulty in adapting it to its present 
form. As the publishers, however, thought that some 
of the facts and arguments of the original paper were 
of sufficient public importance to deserve a more gen- 
eral circulation than could be obtained by a review 
article, I have willingly done my best to make this 
volume of use to general readers. 

No one who lives in one of our great cities— and 
especially no Londoner— can have failed to notice the 
increased attention which is everywhere being given 
to the subject of Epidemic Diseases. As yet, however, 
this interest is but a vague sentiment with the major- 
ity ; and I have been particularly struck, when convers- 
ing even with those gentlemen whose daily avocations 
bring them into constant contact with the classes 
among whom these maladies are chiefly developed and 
fostered, with the fact that, as yet, the bearing of sani- 
tary laws upon the practical questions connected with 

1* (v) 



VI PREFACE. 

prevention and mitigation is so ill understood that it 
can scarcely be said to be known at all. Without pre- 
tending to write what the medical profession would 
receive as a valuable original work, a physician may 
supply the public with very useful information. The 
special source of my own interest in this matter is the 
great prevalence of typhus fever — one of the most 
deadly forms of epidemic disease in London at the 
present day — in the immediate neighborhood of the 
hospital of which I am an officer; a prevalence which 
is so plainly artificial and needless that no medical man 
can observe it without mingled feelings of regret and 
iDdignation. The opportunity now offers itself for 
appealing to the public against that supineness which, 
fostered by a habit of overweening confidence in our 
powers of local self-government, has induced English- 
men to neglect problems which are daily becoming of 
more vital consequence to the well-being of the State. 
No mistake can be more serious in its consequences 
than is the error of regarding the growth of infectious 
diseases as a matter of mere local or personal interest. 
That which is happening in the low "slums " of West- 
minster is happening also in hundreds of places where 
the conditions of daily life are similarly unwholesome ; 
and, unfortunately, the progress of those incidental 
evils which inevitably accompany a certain stage of 
civilization is daily multiplying the centers from which 
infectious disease spreads through the whole commu- 
nity, and aggravating the evil where it already ex- 



PREFACE. Vll 

isted. To meet and check the mischief requires a 
national effort; but until the nation understands the 
elementary facts of the history of preventable disease 
its efforts will be wasted. How miserably ineffective 
our collective attempts at improvement have been will 
be shown in the following pages; nor can we wonder 
at the result when we find official bodies, which are 
charged with the gravest responsibilities as to the care 
of the public health, ignoring so simple a fact as the 
distinction between the contagious typhus of the desti- 
tute classes, and the utterly different fevers which 
depend upon insanitary conditions affecting rich and 
poor almost equally. 

The main object of this essay is to furnish informa- 
tion which may assist the non-medical public to do 
their part in the work of prevention. For the purpose 
of insuring that early isolation of patients which is 
absolutely necessary if infectious diseases are to be cut 
down at the roots, it is necessary that a knowledge 
of the value of the principal premonitory symptoms 
should be widely diffused among the public ; and, ac- 
cordingly, I have endeavored to supply this want in 
the briefest and most intelligible manner. As far as 
possible, the descriptions have been limited to simple 
physical facts, and I have gladly availed myself of one 
important set of phenomena which especially bear this 
character, namely, the changes of animal temperature, 
as tested by the thermometer, which have lately been 
found to furnish most valuable information. It would 



Vlll PREFACE. 

be idle to attempt to convert the public into a body of 
skilled medical observers ; but it is possible, and in re- 
gard to the present subject most important, to teach 
them to perform, scientifically, those duties which de- 
volve on the friends of patients, even before medical 
advice can be summoned ; and, above all, to inform 
them of the real value of those symptoms which make 
it necessary that medical assistance should be at once 
obtained. F. E. A. 

Wimpole Street, March, 1866. 



TABLE OF CONTENTS. 



CHAPTER I. 

INTRODUCTORY. 



Ignorance of the public, a source at once of unnecessary panic 
and of mischievous neglect with regard to epidemic diseases 
— Essentially preventable character of these maladies — Defi- 
nition of the phrase "Epidemic Disease" — List of British 
epidemics — General causes of epidemic disease — Mortality 
from epidemic diseases in London — Premonitory symptoms of 
epidemic diseases, with remarks on the use of the thermom- 
eter for the purposes of diagnosis Page 11 

CHAPTER II. 

FEVERS OF DESTITUTION — RELAPSING FEVER AND TYPHUS. 

Relapsing fever: its genesis simply from circumstances of des- 
titution ; its spread by contagion ; its early symptoms. Typhus 
fever; caused by destitution plus overcrowding in dwellings; 
its intense contagiousness within a small area; the chief 
means of its propagation; pre-eminently a disease of cities; 
its early symptoms Page 24 

CHAPTER III. 

EPIDEMIC DISEASES DEPENDENT ON INSANITARY CONDITIONS IN- 
DEPENDENT OF DESTITUTION — TYPHOID FEVER, CHOLERA, AND 
EPIDEMIC DIARRH03A. 

Typhoid fever, formerly confounded with typhus; really quite 
distinct — Predisposing causes — Exciting causes, chiefly aris- 
ing from defects of drainage — Early symptoms of typhoid. 

(ix) 



X TABLE OP CONTENTS. 

Asiatic cholera: an opprobrium of medicine, but really more 
comprehensible, as to its causation, than some much com- 
moner epidemic diseases — Place of origin — Atmospheric in- 
fluences — Propagation by sewage matters in drinking-water, 
and by sewer-gases — Early symptoms of cholera. Epidemic 
diarrhoea; its relations to cholera; its causes: "dysenteric" 
form of epidemic diarrhoea. Measures of disinfection..PAGE 41 

CHAPTER IV. 

INFECTIOUS EPIDEMIC DISEASES WHICH ARE COMPARATIVELY 
INDEPENDENT OF DEFECTIVE SANITARY ARRANGEMENTS. 

Unsatisfactory state of our knowledge as to the causation of 
those diseases — Scarlet fever; a disease never known to 
originate de novo — Mode of propagation — Intense contagious- 
ness—Precautionary measures — Early symptoms. Diph- 
theria; predisposing causes mostly personal; peculiar nature 
of contagion; early symptoms. Measles; cause not known; 
bad ventilation a source of great aggravation — Early symp- 
toms of measles. Early symptoms of small-pox. Whooping- 
cough; obscurity of original causes; mode of propagation — 
Non-febrile character of early symptoms; dangerous effects 
on weakly constitutions; danger of contagion. Influenza; 
uncertain origin ; rapid propagation ; infectious nature ; 
early symptoms; essentially distinct from common catarrh; 
is often followed by serious constitutional diseases in weakly 
subjects. Brief note on yellow fever. General conclusions 
on the subject of epidemic disease Page 68 



NOTES ON EPIDEMICS 



CHAPTER I. 
INTRODUCTION. 

The British public has just undergone one of those 
panics which it suffers, at certain intervals, from the 
apprehension that epidemic disease of a terribly fatal 
kind is about to devastate the kingdom. The approach 
of the dreaded cholera raised in almost every mind 
vague terrors which the experience of exceptional years 
of pestilence has rendered traditional; and we were 
not unlikely to drift helplessly into mere paralysis at 
the very time when we needed to have all our wits 
about us. Nothing is so effectual in calming the un- 
reasoning fears of a time like the present as the inves- 
tigation of our real knowledge of the evils which we 
dread; it is no slight gain if we learn to view the 
plague with which we are threatened as a scientific 
problem for inquiry rather than a subject for unreason- 
able terror. In the following pages, we shall endeavor 
to show that public sentiment has been unduly excited 
by the prospect of one kind of danger, at the very time 
when other matters of equal, and indeed of far greater 
importance to the national health, are neglected or ill 
understood. We propose to review briefly such con- 

(11) 



12 NOTES ON EPIDEMICS. 

elusions as medical science has been able to announce 
with some confidence, with regard to the special forms 
of epidemic disease to which this country is liable ; and 
it is needless to say that, in a popular treatise such as 
this is designed to be, we must limit ourselves to those 
practical considerations, as to prevention and mitiga- 
tion, in respect of which the general public have duties 
and responsibilities of their own to fulfill. 

In one point of view these epidemic scourges of the 
earth, so far from presenting a specially gloomy aspect 
to the physician, are among the most tangible proofs to 
him of the reality and importance of his work. He 
boldly names them Preventable. He tells the impatient 
generation, which sees its ranks thinned by what seems 
an anomalous, incomprehensible, and irresistible power 
of destruction, that the time will come, and indeed is 
visibly coming, when the diseases which form the largest 
sources of mortality will be extinguished, or confined 
within narrow limits, by the enlarged resources of 
science. It may not be the lot of this generation, or 
of the coming one, to see this consummation ; but the 
student of medicine gathers omens of success in the 
future from past victories in this field, which it is im- 
possible for a layman rightly to appreciate; and his 
faith never wavers, even under the severest pressure of 
present disappointment. No one who is not imbued 
with the spirit of modern medical inquiry can under- 
stand the grounds of this confidence. For example, 
let us consider for a moment the now familiar phenom- 
enon of the disappearance of intermittent fevers, in con- 
sequence of the drainage and cultivation of the marshy 
districts, which are their proper habitat and place of 
birth. To the public, the disappearance (in England, 
for instance) of these diseases, though in itself gratify- 



INTRODUCTION. 13 

ing, suggests no increased confidence in the resources 
of medicine ; for the local annihilation of the pest 
seems to have been as purely accidental as we dare call 
anything. The physician views the matter very dif- 
ferently. He looks upon the whole series of facts ob- 
served in the case as a most useful piece of analysis, 
ready performed to his hand, of which he eagerly avails 
himself in speculating upon epidemic disease in gen- 
eral; and, in fact, there is no single recorded circum- 
stance in medical history which has been more fruitful 
in suggesting thoughts which have led to practical 
results in preventive medicine. It is impossible to say 
how much of our improved knowledge of the mode of 
propagation of many diseases, and specially of typhoid 
fever and cholera, is not, directly or indirectly, due to 
the important considerations forced upon medical men 
by the events which have happened in regard to the 
extermination of ague by drainage. Certain it is, that 
reflection upon this circumstance had the greatest share 
in leading to what we shall hereafter notice as one of 
the very few thoroughly valuable observations which 
have been made in regard to the propagation of cholera 
— the discovery by Dr. Snow of the frequent propaga- 
tion of the disease by impure drinking-water. 

Often, indeed, it has happened, that from the seem- 
ingly most desperate features of modern epidemics, 
there has directly originated the one all-important ob- 
servation which has made possible a whole system of 
preventive regime. It needs but to study the history 
of the Irish Famine fevers, and the subsequent epidem- 
ics of typhus, to find an instance in point. We may 
safely say that the greatest discovery of this century, 
in regard to the causation of epidemic disease, as wit- 
nessed in Great Britain, arose out of the terrible cir- 

2 



14 NOTES ON EPIDEMICS. 

cumstauces of the dreadful Irish famine-pestilence of 
the years 1846 and 184*7. Upon the persons of the 
unfortunate Irish there were worked out, first, the 
great problem of the nature of true starvation fevers ; 
and secondly, the differentiation of the true contagious 
typhus from the former. Such results as this, and the 
discovery of the propagation of typhoid fever through 
the medium of decomposing organic matters, are far 
more than mere medical curiosities ; indeed, as we shall 
hope to show in the proper place, they form the true 
basis, not only for a greatly improved medical treat- 
ment of some of the most important British epidemics, 
but also for a most promising system of sanitary legis- 
lation, which can hardly be much longer delayed. 

It seems necessary, in commencing the discussion of 
our subject, to clear up some elementary points with 
regard to the definition of terms. At the risk, there- 
fore, of appearing to be superfluously minute, we must 
premise that by epidemic diseases we mean to specify 
those maladies which, whether they habitually form 
part of the catalogue of the diseases of any country or 
not, are at intervals imported afresh from without, and 
take, more or less suddenly, a greatly increased devel- 
opment, both as to the number of individuals whom 
they attack and the proportionate mortality. 

Of the human diseases of this class which have in- 
fested Great Britain and Ireland, the following is, for 
practical purposes, a complete list: Plague, typhus 
fever, typhoid fever, relapsing fever, malarial fevers (in- 
cluding intermittents and remittents), sweating sick- 
ness, scarlet fever, measles, small-pox, chicken-pox, 
diphtheria, whooping-cough, influenza, erysipelas, puer- 
peral fever, cholera, and epidemic diarrhoea. 

It would be waste of time, however, to dwell upon 



INTRODUCTION. 15 

all these diseases, because there are a few of them 
which, from their prevalence or their fatality, altogether 
outweigh the rest in practical interest. The malarial 
fevers are now only represented in this country by the 
agues which infest some marshy districts: and the 
deaths from this class of disorders are but trifling in 
number. Small-pox has, it is true, not altogether ceased 
to be occasionally fatal to considerable numbers, but 
we all clearly understand that nothing hinders its ex- 
tinction but the difficulty of enforcing the universal use 
of vaccination. The plague and the sweating sickness 
are happily never known here now, though formerly so 
destructive. Chicken-pox is a trivial complaint. Ery- 
sipelas and puerperal fever do not come under the head 
of serious and widely-spreading epidemics, and their 
outbreak in particular places (such as hospitals, etc.) is 
becoming less and less common now that the first prin- 
ciples of hygiene are well understood by medical men. 
The remaining diseases, which are to form the subject 
of this paper, will be divided into three groups : in the 
first, we shall place relapsing fever and typhus ; in the 
second, typhoid fever, cholera, and epidemic diarrhoea ; 
and in the third, scarlet fever, diphtheria, measles, 
whooping-cough, and influenza. We shall take as our 
text-books the learned works which represent the most 
recent medical science ; without pledging ourselves, 
however, to do more than indicate what seems to be 
the balance of probabilities derivable from a comparison 
of the opinions expressed therein. 

Before speaking of special epidemic diseases, it will 
be well that we say a few words as to the general 
causes of this kind of sickness, among which we must 
seek for the special sources of particular epidemics. 
These are either constant or occasional in their oper- 



16 NOTES ON EPIDEMICS. 

ation. The first kind can be easily illustrated by the 
conditions which prevail where the low- lying delta of 
a slowly flowing river has become the depository of a 
great quantity of decaying organic matter, or by the 
state of things which exists when sewage matters 
habitually contaminate drinking water, or sewer gas 
always mixes in large quantity with the atmosphere. 
In all these examples we see elements (though not all 
the elements) of epidemic disease lying constantly in 
readiness for mischief. The occasional causes may be 
illustrated by the influence of changes in the atmo- 
sphere (particularly as regards temperature, moisture, 
and the rate of movement of the air), and by the vari- 
ous circumstances which may produce distress and pri- 
vation of food among large numbers of persons at a 
particular time. But by far the most important of 
these occasional causes is that influence which is known 
by the name of contagion ; this word expressing the 
idea of the communication of a material substance which 
can excite the disease in the body. Our readers are 
probably aware that modern writers for the most part 
associate with the idea of contagion the further theory 
that the communicated poison is of the nature of a fer- 
ment, and that the characteristic disturbances which it 
sets up in the organism are due to a kind of fermenta- 
tive movement; hence the name "Zymotic (or fermen- 
tative) diseases." During the fermentative process the 
secretions of the infected person become charged with 
matters, which in their turn are capable of setting up 
the zymotic process in healthy organisms : these mat- 
ters are sometimes volatile, and sometimes not, or they 
may have very different degrees of volatility ; and upon 
these differences depends the distance to which the 
atmosphere round an infected person will be charged 



INTRODUCTION. 17 

with the pernicious influence. But even in the case of 
the n on -volatile zymotic poisons, infection may be con- 
veyed by the direct application of the morbid matter to 
a part of the body from which it can be readily ab- 
sorbed into the blood ; as by the application of small- 
pox or cow-pox matter to a wound, or by swallowing 
the vitiated secretions from patients suffering from 
typhoid fever or cholera. Lastly, it must be noted that 
many of the best observers believe that some diseases 
which are not contagious are yet dependent on the 
action of a zymotic poison; as, for instance, the ordi- 
nary English agues. 

As regards the nature of the several zymotic poisons, 
little more is known than that they are probably or- 
ganic in their chemical composition ; but it may be said 
that the belief rather gains ground, that in their active 
state these morbid matters consist of or retain living 
organisms. This question, though far too little eluci- 
dated to permit of detailed argument, has most import- 
ant relations to the question — whether all or any of the 
zymotic diseases are capable of being produced de novo, 
and in the absence of specific germs derived from ex- 
isting cases of the particular disease. In a treatise like 
the present, it is impossible to do more than to point 
out, in treating of individual diseases, the evidence 
which bears most strongly on this disputed question. 

In order to give a general idea of the importance of 
those epidemic diseases which we propose to discuss, 
it may be well to quote here the evidence afforded by 
the Registrar-General's abstracts of the mortality in 
London for the thirteen years from 1852 to 1864 inclu- 
sive. These returns show that in that period of time 
the mortality in London, from all causes, was 719,958. 
In the same period, the mortality from " zymotic" dis- 
2* 



18 NOTES ON EPIDEMICS. 

eases was 218,998. Of these deaths, 41,664 were 
caused by scarlet fever or diphtheria (these two dis- 
eases are not accurately separated), 18,256 by measles, 
26,892 by whooping-cough, 13,160 by cholera (10,708 
of these in the single epidemic of 1854), 29,995 by diar- 
rhoea, and 31,937 by " typhus" (including not only true 
typhus, but relapsing fever and typhoid), and only 
1168 by influenza — no serious outbreak of the latter 
disease having occurred within the years specified. 

We shall conclude the present chapter by mention- 
ing some circumstances which may give warning of 
attacks of epidemic diseases, and may often enable 
friends of patients to form a rough but serviceable 
estimate of the probable gravity of the impending affec- 
tion. 

Of the diseases which we are about to discuss, some 
are, and some are not, febrile in the manner of their 
commencement : of the former class are typhus, typhoid, 
relapsing fever, scarlet fever, measles, and influenza ; 
diphtheria may be said to hold a half-way position; 
while cholera, epidemic diarrhoea, and whooping-cough 
belong to the non-febrile class, as regards the way in 
which they begin. 

The febrile kind of epidemics usually announce their 
attack by striking premonitory symptoms. In all of 
them, if the affection run at all a typical course, there 
is a. period of greater or less duration, a few hours or 
a few days as the case may be, between the exposure 
to the infecting poison and the outbreak of distinct 
symptoms : but usually for some time before the latter 
event the patient loses his appetite, and experiences, 
and shows in his looks, an unaccountable depression. 
This culminates most commonly in a burst of shiver- 
ing, not unfrequently accompanied or followed by vom- 



INTRODUCTION. 19 

iting; a chilly feeling lasts for some time, and then 
gives way to sensations of unusual and steadily-increas- 
ing heat, till that burning state of the skin is attained 
which is popularly thought to be typical of fever; there 
are the greatest differences, however, between different 
diseases, and even between different cases of the same 
disease, as to the degree of flushing of the face. 

Whenever a patient shows such symptoms as these, 
he should be at once isolated in an apartment possess- 
ing not less than 1500 to 2000 cubic feet of space, and 
with the freest means of subsidiaiy ventilation : unless 
the weather be very hot there should be a fire, and the 
windows must be constantly open. No bed- hangings, 
curtains, or carpets should be allowed. This is more 
especially necessary if, among the symptoms, there has 
been sore throat, and the patient has never had scar- 
latina, — or severe pain in the back, and sickness, and 
the patient has been exposed to small-pox, — or if there 
be great nervous prostration or delirium, and the patient 
has been within the possible range of typhus contagion. 
The most anxious watch must now be kept upon the 
skin, and the appearance of anything like an eruption, 
especially if it comes out on several parts of the body, 
should be the signal for summoning medical advice, 
even in cases where the preliminary symptoms may 
have been ever so mild. The time of appearance of 
the eruption varies from twenty-four hours to nine or 
ten days, from the commencement of the febrile symp- 
toms in the various febrile diseases; and, in relapsing 
fever, there is never any specific eruption at all. Be- 
sides this, there are many instances of the complete, or 
almost complete, absence of eruption, even in scarlet 
fever and other epidemic diseases, which are ordinarily 
accompanied by a rash. Some more early and certain 



20 NOTES ON EPIDEMICS. 

criterion of the nature and seriousness of the disease is, 
therefore, a great desideratum for the friends of the 
patient, and, fortunately, we are now in a position to 
suggest one test of this kind, the value of which is very 
great. 

Recent medical observation has placed in our hands 
a means of distinction between different febrile mala- 
dies, and a most useful calculus of the gravity of an 
existing disease, which we must here specify, viz., the 
thermometer. 

It has long been known that the healthy human body 
possesses the remarkable property of retaining an al- 
most complete equality of temperature in its deeper 
parts, under all the varying circumstances of external 
cold or heat. The temperature of the armpit, for in- 
stance, which is a part protected from the influence of 
external changes, remains always, during health, at the 
level of 98° to 99° Fahrenheit. And this is taken as 
the standard in the ordinary circumstances of life in 
temperate climates. In severe diseases of many kinds 
(not merely in fevers) this standard is exceeded, some- 
times even to the extent of eight or nine degrees ; and 
it is a singular fact that this increased heat begins to be 
manifested to thermometric observation even in those 
early stages of acute diseases, when the patient's own 
delusive sensations would lead him to believe that there 
was a great reduction of animal heat, as, for instance, 
in the shivering fit which forms the first stage of an 
attack of ague. 

From the large number of observations which have 
been made by Wunderlich and many other continental 
observers, and in our own country by Dr. Sidney Ringer 
and Dr. Aitken, the following facts stand out as pre- 
eminently valuable in the appreciation of the character 



INTRODUCTION. 21 

of acute diseases. If the thermometer rapidly rises as 
high as 101° to 105° Fahrenheit, the degree of fever 
may be known to be severe. When the temperature 
exceeds 105°, the complaint is dangerous to life, and 
the danger increases rapidly with every successive de- 
gree of added heat. On the contrary, if during the 
first two or three da}^s of illness the temperature never 
rises above 100°, the complaint is probably a trivial 
one, whatever its exact nature may be. On the whole, 
it is a good rule for the guidance of the public that a 
temperature exceeding 100°, however mild may be the 
general symptoms which the patient may present, is a 
proof of the necessity of immediately applying for med- 
ical advice. 

These leading facts are sufficient to show the general 
importance of thermometric observations ; and we shall 
endeavor to show, in treating of particular epidemic 
diseases, the more special items of information which 
may be gained in this way. The thermometer is an 
instrument which for many important medical purposes 
is as necessary to non-professional persons as to medi- 
cal men ; it remains for us now to indicate the precau- 
tions which must be observed in its application. 

The kind of instrument which must be used is that 
with a naked bulb, and a white backing to its stem, on 
which the degrees are marked ; Mr. Cassella, of Hatton 
Garden, makes very good ones of this kind, which are 
generally adopted by medical men ; but cheaper instru- 
ments, of German make, can be obtained from Griffin, 
22 Garrick Street, Covent Garden. 

The "Self-Registering Maximum" form of thermo- 
meter is the most convenient for the use of non-profes- 
sional persons, who are not accustomed to the daily 
employment of the instrument; the purchaser should 



22 NOTES ON EPIDEMICS. 

obtain from the maker full instructions as to the adap- 
tation of the index or register. No observation should 
be made till the patient has been quietly resting in bed 
for at least an hour. The bulb of the thermometer 
should then be placed deeply in the armpit, the arm 
being folded across the chest, and the bed-clothes so 
arranged to cover the projecting stem as high as the 
marking of 90°, or thereabouts. The patient must lie 
perfectly still for at least ten minutes ; the thermometer 
may then be withdrawn, when the register will remain 
stationary at the highest level which the mercury has 
reached. 

A very slight amount of reflection will show the 
value of this mode of investigation, in assisting the 
friends of a patient who exhibits so-called " feverish " 
symptoms to a decision as to the propriety of taking 
some important steps, and particularly as to seeking 
medical help. It is absolutely necessary, however, that 
the application of the thermometer should first be prac- 
ticed on the healthy body, before we venture to rely on 
its indications in disease, even for these limited pur- 
poses for which alone laymen could be recommended 
to use it. The mother of a family should always be 
skilled in the application of the instrument, since no- 
thing is more uncertain and delusive than the sensations 
of young children who complain of feeling ill, and the 
application of the hand to the skin is a very poor and 
imperfect method of determining real temperature. In 
speaking of particular febrile diseases, we shall show 
that, besides the general information as to the gravity 
or triviality of a feverish disturbance which the ther- 
mometer can impart, it sometimes enables the observer, 
by its sole authority, to determine that a particular 
disease is or is not present. 



INTRODUCTION. 23 

The warning symptoms of those epidemic diseases 
whose commencement can hardly be said to present 
febrile phenomena at all, are so peculiar in the case of 
each individual disease, that we can lay down no gen- 
eral rules for determining their nature or severity, 
beyond the fact of the prevalence or non- prevalence of 
the disease in the neighborhood at the time. All other 
questions must be deferred to subsequent chapters. 



CHAPTER II. 
FEVERS OE DESTITUTION. 



Relapsing Fever and Typhus. 

The three groups of epidemic maladies which we 
have already marked out have been arranged in the 
order in which we have placed them, on the principle 
of commencing with those which exhibit the simplest 
and the most intelligible phenomena. Our first group 
contains two diseases,— relapsing fever and typhus,— 
which owe their origin, or at least their developments, 
to scarcity of food, and to the various social miseries 
which follow necessarily in the train of such scarcity. 

Relapsing Fever.* -Relapsing fever may be de- 
scribed as presenting the simplest type, as regards its 
mode of origin, of any of the epidemic diseases; for it 
has been almost certainly proved to result directly from 
privation of food. The evidence seems remarkably clear 
and satisfactory. Every epidemic of the disease which 
has been recorded was preceded by extreme destitution 
of the poor, produced either by the failure of crops, or 
by some artificial circumstances which tended to throw 
large numbers of the lower classes out of employment. 



• Relapsing fever is scarcely ever witnessed in the United States. 
— A*r. Ed. 

(24) 



RELAPSING FEVER. 25 

Unfortunate Ireland reckons it among the sad features 
of her history that she has been visited with terrible 
frequency by this disease ; and the outbreaks have been 
always preceeded by periods of severe distress, chiefly 
from failure of the crops. But there is no monopoly of 
the disorder : wherever famine and want have prevailed 
in extraordinary degree, there relapsing fever has ap- 
peared. Perhaps the most fearful — as the most sug- 
gestive — narratives of this fever which we possess, are 
those of the Skibbereen and Mullingar epidemics in 
1846 and 1847. Dr. Donovan, writing of the condi- 
tion of the famine- stricken peasantry of Skibbereen, 
says, " The skin exhaled a peculiar fetid odor, and was 
covered with a brownish filthy-looking coating, almost 
as indelible as varnish : this I was at first inclined to 
regard as incrusted filth, but further experience has con- 
vinced me that it is a secretion poured out from the 
exhalants of the body." And Mr. Kelly, speaking of 
the same phenomenon at Mullingar, says, "Its smell 
was peculiar, not fetid or heavy, but somewhat like 
burning straw, with a musty odor ; and, strange to say, 
there was not a single pauper in the workhouse, with 
whom I had any intercourse, that did not evolve a 
similar odor when heated, even by the slightest exer- 
tion." Together with these repulsive symptoms there 
were others which, as Dr. Murchison remarks, strongly 
recall the phenomena noticed in the observations of 
Holland on the state of the starved poor in Manches- 
ter, viz., emaciation, languor, listlessness, despondency, 
and giddiness ; followed by staggering, dimness of sight, 
delirium, stupor, and coma; or by quick pulse, flushing 
of the skin, dry tongue, intolerance of light, neuralgic 
pains, and delirium ; all the secretions of the body be- 
coming at the same time vitiated. It is in such cir- 

3 



26 NOTES Ox\ EPIDEMICS. 

cumstances that the fever is generated; but once 
established, it assumes a contagious character, and 
may spread to those who are not themselves in a state 
of destitution, though for this purpose very intimate 
communication with the sick appears to be necessary. 
The fever derives its name from the fact that the orig- 
inal access lasts only a few days, and then subsides ; 
but, subsequently, relapses very frequently occur : there 
is no specific skin eruption, and the mortality fortu- 
nately is but small. 

The symptoms of an attack of relapsing fever are 
remarkable for their sudden occurrence and their early 
intensity. Severe shivering, chilliness, and frontal head- 
ache not unfrequently develop themselves as the earliest 
signs of positive illness ; and great febrile excitement, 
indicated by great heat of the skin (102° to 107° Fahr- 
enheit by thermometer in armpit), intense thirst, flush- 
ing of the face, and very rapid pulse is conspicuous even 
within the first day or two ; to these is soon added, in 
the great majority of cases, violent and repeated vomit- 
ing of a greenish bitter fluid. Yery soon pains in the 
muscles and joints are also nearly always present ; and 
when these pains are especially manifested in the back 
they form, together with the vomiting, a source of doubt 
as to whether the malady may not ultimately tarn out 
to be small-pox — a doubt which sometimes cannot be 
laid to rest until the fourth or fifth day (inclusive), from 
the commencement of the symptoms, has passed, by 
which time the characteristic eruption of small-pox 
would probably have appeared. There are two symp- 
toms, however, which very commonly present them- 
selves, even in the early stages, which are highly diag- 
nostic of relapsing fever (when combined with the 
intense febrile excitement already described), namely, 



TYPHUS FEVER. 21 

oppressed and anxious breathing, and jaundice of the 
skin and eyes. And, if to these are added fits of sweat- 
ing which bring no relief to the febrile heat of the skin, 
the probability of relapsing fever is greatly increased. 
Along with all these symptoms, even when they are 
severe, there is a much less degree of prostration than 
occurs in the early stages of typhus. 

The above phenomena, occurring in an extremely 
destitute person, would at once make us almost cer- 
tain of the nature of the disease ; occurring in a well- 
nourished individual, their value would depend chiefly 
on the amount of probability that the sufferer had come 
in personal contact with individuals infected with re- 
lapsing fever. The early symptoms are so severe that 
no sensible person could long delay applying for medical 
advice. 

Such, in brief, are the early symptoms of uncompli- 
cated relapsing fever — the fever of pure starvation ; a 
disease which has been recently forced upon our atten- 
tion, at the time of the alarm of the so-called "plague" 
in Russia ; on this occasion, as in all others, the cause 
of the epidemic was obvious. 

Typhus Fever. — Given, now, a set of individuals 
much in the condition, as to bodily nutrition, of the 
candidates for relapsing fever, it needs but one acci- 
dental circumstance, apparently, to procure the out- 
break among them of a far more formidable malady, — 
the true typhus, — British typhus, as it has often been 
called, from the frequency with which it prevails in our 
islands. Abundant evidence has been adduced to illus- 
trate the "predisposing" and "exciting" causes, to use 
the ordinary medical terms, of this terrible disorder. In 
the first place, typhus, like relapsing fever, is pre-emi- 



28 NOTES ON EPIDEMICS. 

nently a disease of the poor. It is saddening to reflect 
upon the ignorance which has prevailed, among the 
public, as to the history of this disease ; an ignorance 
which is well marked by the general tendency to con- 
found it with typhoid fever — a disorder which, as will 
be shown presently, owns a widely different parentage. 
Typhus fever is the curse of our large over-crowded 
cities, as typhoid is of our primitive, innocent ham- 
lets, and our gossiping, ill-drained country towns ; and 
everything about the two diseases, their causes and 
symptoms equally with the limit of their range, is 
widely distinct in the two cases. Typhus first makes 
its "nest," to use a cant word which is dismally preva- 
lent just now, in the courts and alleys inhabited by the 
very poor. Unlike relapsing fever, it is a very mortal 
disease ; and, moreover, the contagion is much stronger 
than that of relapsing fever. It is most unquestion- 
ably fostered or discouraged, according to the destitu- 
tion or prosperity of the population : on this point it is 
very instructive to contrast its frightful ravages in the 
crowded Lancashire districts, among the poor Irish 
after the famine of 184*7, and its non-appearance or 
trifling development among the sufferers from the re- 
cent Cotton Famine, who had the benefit of an abund- 
ant and pervading charitable assistance, which pre- 
cluded anything* like starvation on the large scale. 
Yery many similar instances might be produced, show- 
ing the same influence of good nourishment, in enabling 
a population to resist the attacks of this terrible disease, 
and vice versa. 

If famine be the great predisposing cause of typhus, 
overcrowding is something more ; for there is much 
evidence to show that it can actually excite the disease 
in destitute persons. In regard to this, the various 



TYPHUS FEVER. 29 

synonyms under which typhus has been described at 
different times are highly suggestive : the old terms — 
"jail distemper," "camp fever," "hospital fever," and 
the like, point to instances in some of which, no doubt, 
the disease was only fostered by crowding and deficient 
ventilation, but in great numbers of which typhus was 
probably actually bred from the circumstances of the 
time and place. It is, of course, impossible here to 
recite the evidence for and against the doctrine of 
typhus-generation de novo; but as a typical instance 
of the class of facts which lead us to affirm the theory, 
let us hear a narrative by Dr. Murchison. "Again, 
after a complete absence of typhus for six months, 
several cases occurred in the spring and summer of 
I860. I visited the localities whence all the first cases 
came. Several came from a court at Limehouse, where 
the fever originated in an underground cellar, contain- 
ing 912 cubic feet of space, with one window, which 
was never opened. This cellar was inhabited by eight 
persons (114 cubic feet to each*), who were in a state 
of great destitution. There had been no fever before 
in the court or neighborhood ; but from this cellar it 
spread by contagion to several other houses in the 
same court. Another group of cases came from Pump 
Court, White Horse Alley, Holborn. A family, con- 
sisting of father, mother, and four children of the re- 
spective ages of eighteen, fifteen, eleven, and nine, 
inhabited a room on the ground floor, whose dimensions 
were . . . . 10T2 cubic feet. All six slept in this room, 
so that each had only 118 cubic feet of space, which 
was still further diminished by a great accumulation of 
furniture In the night, when the beds were let 

* About as many as are contained in a moderate-sized grave. — Am. Ed. 

3* 



30 NOTES ON EPIDEMICS. 

down, the floor was literally covered with furniture. 
There was one door and one window; the door was 
always shut at night, and the window-shutters closed. 
The window looked into a court a yard and a quarter 
wide, on the other side of which was a high wall, and 
beyond this a range of high houses. The family had 
resided in this house for many months, and had latterly 
been in very reduced circumstances, owing to the father 
being out of work. Four of the six took typhus, which 
at the time was unknown in the neighborhood, and 
indeed was only met with in one or two distant local- 
ities throughout the metropolis. In a third case inves- 
tigated, the circumstances were very similar." Take 
another example, which has come under our own eyes 
within the last few weeks. There is no quarter of 
London in which typhus has raged with more fatal 
effect than in the low "slums" of Westminster. One 
spot in particular, has been long indicated by the med- 
ical officers of the parish as peculiarly fruitful of this 
disease, and, at the request of one of these gentlemen, 
we lately paid it a visit. " Smith's Rents " and " Smith's 
Place " are two miserable courts situated to the north of 
Victoria Street, the first running out of a main street, the 
second turning out of the first at a right angle, and lead- 
ing to nowhere, a mere cul-de sac in a wilderness of 
backs of houses.* All the tenements in these two courts 
are miserable two-storied buildings, with no thorough 
ventilation, each story consisting of a single room, in- 
habited by at least one family ; the two floors united 
by a narrow staircase, so cranky and winding that it is 
a matter of difficulty to ascend it. The average total 

* There are many places in all our large cities fully as bad, if not 
worse than those mentioned by the author as situated in London. 
See Sanitary Report of New York, etc. — Am. En. 



TYPHUS FEVER. 31 

space allowed for each inmate does not exceed 180 
cubic feet, and it is greatly less than this in individual 
instances. We particularly inspected a house in Smith's 
Place which had already yielded seven cases of typhus 
within about as many weeks. The patient whom we 
went to see was a boy of about nine years of age ; he 
was one of a family of seven, who inhabited a ground- 
floor room, one of the foulest and most stifling apart- 
ments we ever entered. The only aperture (except the 
front door) for light and air was one window, about 
three feet square — a casement which could only be par- 
tially opened : the whole room reeked with the odor 
which any medical man would at once recognize as that 
of typhus. In correspondence with the general air of 
squalor which distinguished this house are the sanitary 
arrangements, common to the whole of Smith's Place ; 
the whole court, containing nine houses, is provided 
with two filthy, ruinous water-closets, in a state of 
nauseous impurity which it is impossible to describe, 
and with no water supply (the water having been cut 
off, nobody could tell how or where, some weeks pre- 
viously), and one dust-bin, open at the top, which is 
emptied on an average once a month ! 

In Smith's Rents we visited three typhus patients 
who were even worse off; they were lying in a room 
on the upper floor, the staircase leading to which was 
about two feet wide; the room was inhabited by five 
persons, who each enjoyed an allowance of about ninety- 
five cubic feet of space ;* there was only one small win- 
dow, and the apartment stank so as to produce the most 
violent nausea in those entering it from the outer air. 



* Somewhat less than the space allowed to a corpse in a grave of 
the ordinary size for an adult. — A>r. Ed. 



32 NOTES ON EPIDEMICS. 

These descriptions might be multiplied indefinitely, from 
the experience of the last three or four years. It is a 
melancholy fact that typhus, which was formerly a dis- 
ease of only occasional occurrence, has become, to all 
appearance, a permanent fixture in London ; and those 
who know most of the haunts of the disease will find 
great difficulty in explaining this, save on the principle 
that the aggregation of the sufferers rules the intensity 
and spread of the disease. Overcrowding in the low 
parts of our great towns necessarily implies much more 
than the mere concentration of human exhalations. It 
destroys feelings of self-respect among the poor, and 
leads them to neglect cleanliness, and thus the foulness 
of their apartments is aggravated. Typhus fever, gen- 
erated in or imported into dwellings of this class, as- 
sumes a very intense degree of contagiousness ; but the 
nature of the contagion is peculiar. Its operation is 
intense within a small range of distance round the in- 
fected object; but at a greater distance, or when the 
poison is diluted with free currents of pure air, the by- 
stander encounters but small risk. In the stifling rooms 
of the poor in our great cities, the whole air is full of 
poisonous exhalations; and, moreover, they cling to the 
furniture and walls of the apartments ; so that unless 
a room of this kind be thoroughly disinfected by wash- 
ing, lime-whiting, and the freest ventilation after a 
typhus patient has occupied it, it is a most dangerous 
residence for any susceptible individual. The clothes 
of the sufferer are also capable of conveying the disease. 
But except by the contagion of personal intercourse, the 
fever rarely spreads even from room to room, far less 
from house to house ; and this accords exactly with the 
experience of the London Fever Hospital, in which, the 
typhus cases being kept in separate wards which are 



TYPHUS FEVER. 33 

highly ventilated, the fever never spreads to other parts 
of the building; whereas, in those general hospitals 
which still continue the plan of mixing typhus cases 
with others (in wards which it is impossible to venti- 
late up to the proper typhus mark), the disease has 
often spread with serious effect. 

A remark must here be made which is of the greatest 
consequence. The attention of hospital committees 
ought to be directed to the crying necessity which ex- 
ists for the establishment, at every general hospital, of 
separate wards devoted to the isolation of cases of the 
more contagious fevers, and especially of typhus. In 
our view of the case it is difficult to apply terms of 
reproach sufficiently strong to the practice of mixing 
cases of a powerfully contagious fever with patients 
who are suffering from miscellaneous diseases. One 
has only to state the case to show the impropriety of 
the proceeding. A poor person, suffering perhaps 
from a quinsy, or some other disorder in which there is 
no likelihood of any other result than a speedy recovery, 
is admitted to a hospital, and, while he is lying defense- 
less on his back, the authorities place in the next bed 
to him a typhus patient, who communicates to him a 
fatal disease, of which he dies. This is no fancy state- 
ment of the case; it is what has happened over and 
over again during the progress of typhus epidemics, 
and especially during the great epidemic which has 
now for so long a time raged continuously in London. 
It may be said that a simple remedy for this kind of 
mischance would be the exclusion of all cases of the 
more contagious fevers from general hospitals, and, in 
fact, some hospital physicians have proposed to adopt 
this course rather than expose their other patients to 
the unjustifiable risk of contracting a highly mortal dis- 



34 NOTES ON EPIDEMICS. 

ease. But, in the first place, until the parishes do their 
duty in the manner which we shall presently point out, 
it is vain to suppose that the single fever-hospital can 
possibly accommodate all the cases of highly contagious 
fevers which are, or ought to be, treated in hospitals. 
And secondly, it must every now and then happen, 
even where the greatest care is exercised, that a person 
will be admitted who is supposed to be laboring under 
some ordinary complaint, but who is, in truth, infected 
with typhus, or some other highly contagious disease 
which is in a latent condition. Under these circum- 
stances it is a matter of the highest importance that 
there should be the means of immediately separating 
him from the non-febrile patients when the real char- 
acter of his complaint declares itself. Formerly a 
notion prevailed that the aggregation of several cases 
of infectious disease within the same ward was in it- 
self an extremely mischievous thing, as tending to con- 
centrate the poison and intensify its malignity. This 
is now known to be a fallacy, when taken as a general 
proposition. It is quite true that the poison of con- 
tagious fevers becomes highly dangerous when it is 
diluted with less than a certain quantity of atmospheric 
air. But by allowing a large amount of cubic space 
(1500 to 2000 feet) to each patient, and providing for 
the free circulation of currents of air, the concentration 
of the poison may be entirely avoided, even in a ward 
which contains thirty or forty typhus patients. More 
than this ; it may be broadly stated that it is impossi- 
ble, in a ward which contains miscellaneous patients, 
some of them suffering from inflammatory diseases to 
which anything like draughts of cold air would be 
highly prejudicial, to keep up a system of ventilation 
free enough to effectually dilute the poisonous emana- 



TYPHUS FEVER. 35 

tions of even a single typhus patient ; and, as a matter 
of fact, the introduction of a single typhus patient into 
a ward which was quite sufficiently ventilated for gen- 
eral purposes has frequently caused the disease to 
spread from bed to bed with most lamentable results. 
A fever ward should, therefore, be a special affair, with 
an extra amount of ventilation. Where it is possible, 
the fever wards should be placed in a separate block of 
buildings, and, where this is not the case, at least the 
most jealous care should be exercised to prevent com- 
munication between the attendants of these wards and 
those of the wards which contain miscellaneous pa- 
tients. With these precautions we believe that typhus 
may be absolutely shut within the walls of the apart- 
ments devoted to its treatment. 

Typhus is a disease especially of the winter season. 
It commences to increase rapidly at the cessation of the 
harvest operations, when crowds of ill-fed Irish and 
others swarm into the cities : sometimes actually bring- 
ing the infection with them. It is aggravated*by any 
cause which throws numbers of persons out of work, 
since this implies both defective nutrition and increased 
overcrowding. It very commonly breaks out in the 
"trarnp-wards," or places for the "casual" poor, which 
a late act of Parliament obliges the boards of guar- 
dians to provide in the workhouses; and the scandal- 
ous inattention which the authorities too frequently pay 
to ventilation and cleanliness in these wards is often 
the direct cause of the disease. W 7 e may mention one 
instance of this carelessness of management which 
speaks volumes. In the interesting and clever narra- 
tion of the experiences of an amateur "casual" in the 
Lambeth Workhouse, lately given in the Pall Mall 
Gazette, there was one incident which excited disgust 



36 NOTES ON EPIDEMICS. 

in all who read it, but which might also justly cause 
indignation and alarm. The "mutton-broth" like ap- 
pearance of the water in which the writer was obliged 
to bathe was, of course, due to the fact that one or 
several dirty people had already been washed in it. 
Our own experience of workhouse tramp-wards enables 
us to state that it is quite a common practice to bathe 
several persons in the same water. It is needless to 
say that the propagation of infectious disease of all 
kinds is favored in the highest degree by such a custom ; 
and the mere fact that it has only recently attracted 
attention, is conclusive evidence of the thorough inca- 
pacity of the guardians to whose hands the manage- 
ment of workhouses is committed. But, in truth, the 
whole arrangement of the casual wards, at any rate in 
London workhouses, betrays the same stupid igno- 
rance; in no respect is this more clearly shown than 
by the excessive overcrowding which is allowed in 
these apartments, the sleepers usually lying quite close 
to each«other, so that their breath and the exhalations 
from their skins must mix, and become concentrated in 
the most dangerous manner, particularly as there is sel- 
dom anything like an efficient set of windows or venti- 
lators. Clearly, the department of casual relief ought 
to be administered in separate buildings, with extra 
allowance of space: for the dangerously ill-fed and 
sometimes actually fever- stricken class of casual poor 
cannot, without great danger, be crammed into wards 
which afford only 200, 300, or 400 cubic feet of space 
to each sleeper. The most scrupulous cleanliness (in- 
cluding washing of the entire body) ought to be en- 
forced on all who are not too ill ; and all the clothes 
ought to be boiled or baked at a temperature of 212°, 
in order to disinfect them. 



TYPHUS FEVER. 3? 

One of the greatest causes of the spread and contin- 
uance of typhus in cities is the want of fever -houses, 
which should be built in each parish ; were these estab- 
lished, and were the parish medical officers empowered 
by law to order the removal to them of all cases of 
typhus occurring in rooms under a certain specified 
size, an enormous diminution of the disease would take 
place. Further, the vestries might be empowered, and 
then compelled (for they will never do it properly of 
their own accord), to see that a proper and copious 
water supply is laid on to every house by "constant 
service," or else stored in proper tanks, which should 
be frequently inspected, to insure their cleanliness. 
And on the removal of a fever-stricken family from a 
room, a thorough cleaning and ventilation for three or 
four weeks ought to be compelled before new lodgers 
are admitted. Till this is done the prevalence of typhus 
will continue and increase : and in connection with this 
probability there is one really appalling consideration. 
Many of the best modern observers strongly believe 
that the Oriental plague, which formerly committed 
such ghastly ravages in England, was only typhus 
fever, aggravated by the abominable sanitary arrange- 
ments which were characteristic of the age. But if we 
are to go on crowding our populations more and more 
into the towns, and neglecting their lodgment and their 
means of cleanliness, as we have been doing lately, 
there seems no reason whatever why plague should not 
visit us again ! 

There is another important source of the propagation 
of typhus fever, to which public attention has very 
properly been drawn, — we refer to the conveyance of 
patients to the hospitals in ordinary cabs, which are 
immediately afterward employed by the public. It is 

4 



38 NOTES ON EPIDEMICS. 

quite unnecessary to say a word to prove the immense 
clanger of the spread of contagion in consequence of 
such a proceeding. Doubtless these infected street- 
cabs are the chief, if not the sole causes of those occa- 
sional cases of typhus among persons in the better 
ranks of life, who have never been brought into any 
direct personal communication with persons suffering 
from the disease, and the sanitary condition of whose 
dwellings is perfectly good. Of course there should be 
vehicles in each district, specially constructed for the 
removal of fever patients. We are glad to notice that 
a recently formed association proposes to supply this 
want ; but, in our opinion, the undertaking should be 
carried out by government, or by the parish authorities, 
and severe penalties should be imposed on any one 
venturing to remove a patient suffering from contagious 
fever in an ordinary public vehicle. 

The early symptoms of typhus fever may be de- 
scribed as follows : A person who has been exposed 
to direct contact, or very close companionship, with a 
typhus patient, or has been living for some time under 
circumstances of destitution in an overcrowded dwell- 
ing, or has slept in an apartment recently inhabited by 
a typhus patient, experiences (either suddenly, or after 
a few days of preliminary uneasiness, loss of appetite, 
and sleeplessness) a sense of chilliness or actual shiver- 
ing, accompanied by a feeling of very great prostration. 
The chills are succeeded by heat ; and chills and heat 
recur at irregular intervals for two or three days : but 
these feelings are only "subjective." If the thermo- 
meter be applied to the armpit, it will be found to mark 
a temperature as high as from 102° to 104° Fahren- 
heit, even on the first, second, or third day; the tem- 
perature is always highest at night, and sinks to a 



TYPHUS FEVER. 39 

degree or even two degrees lower by the middle of the 
day, which represents the time of its- minimum. On 
the evening of the fourth day, most commonly, though 
there is much variation in this respect, a great rise in 
the temperature takes place, — it may even go up to 
108°, or higher; and this symptom immediately pre- 
cedes or accompanies the appearance of the characteris- 
tic eruption. This eruption is variable in character, 
within certain limits ; but, in the great majority of in- 
stances, it resembles that of measles; it consists of 
irregularly-shaped spots or blotches, which are most 
thickly strewn upon the trunk of the body, and gen- 
erally have the tint of stains made with mulberry 
juice ; they disappear on pressure with the finger, and 
reappear when the pressure is removed. The general 
sense of great depression which marks even the early 
stages of typhus is usually accompanied by great gid- 
diness, noises in the ears, trembling of the limbs, and, 
in bad cases, a curious kind of insensibility, which is 
medically termed "coma vigil," in which the patient 
lies with his eyes wide open, with no approach to true 
sleep, but perfectly indifferent to all that goes on around 
him. The intellect is confused, and the memory im- 
paired, almost from the first, and very commonly deli- 
rium comes on, and steadily increases. The countenance 
of a typhus patient is one of the most characteristic 
features of his disease; it presents a curious earthy 
tint, which is quite different from mere paleness on the 
one hand, or red flushing on the other; and almost 
more characteristic of the complaint is the attitude 
which the sufferer assumes — lying on his back, and 
slipping feebly down into the bottom of the bed. 

In concluding our remarks on typhus fever it is neces- 
sary once more to insist upon its great contagiousness 



40 NOTES ON EPIDEMICS. 

to those who are engaged in close personal attendance 
on the patient. " For this reason the nurses, and the 
resident medical officers of hospitals where typhus cases 
are treated, are especially liable to take the disease, and 
a practical conclusion of the highest importance results 
from this fact. Where it is possible, no nurse should 
be allowed to wait on a typhus patient who has not 
already had the disease, for it very seldom attacks the 
same person twice. Where this cannot be managed, 
at any rate the nurse should be a young and healthy 
person, for such individuals commonly have the disor- 
der in a mild or at least not a fatal form ; whereas the 
mortality is very high among those who contract the 
disorder at an advanced period of life. And in all 
cases great care should be taken not to approach typhus 
patients when one is in a state of great fatigue or of 
fasting, for under these depressing circumstances the 
organism is especially susceptible of the morbid influ- 
ence ; and we know of many cases where the system- 
atic avoidance of this kind of imprudence has enabled 
nurses and resident medical officers of fever hospitals, 
who were constantly exposed to the contagion of 
typhus, to resist its attacks altogether. 



CHAPTER III. 
EPIDEMIC DISEASES 

DEPENDENT ON INSANITARY CONDITIONS, INDEPENDENT 
OF DESTITUTION, TYPHOID EEVER, CHOLERA, EPIDEMIC 
DIARRHOSA. 

Typhoid Fever. — If typhus be the disease, par 
excellence, of crowded, intensely competitive cities, 
typhoid fever, which was long confounded with it, is 
now-a-days the special epidemic of the slumbrous, con- 
servative rural districts. This fever is the type of our 
second group of epidemic diseases, — those, namely, 
which are scarcely at all contagious, in the common 
sense, and which, as far as our knowledge goes, appear 
to derive their origin, and certainly receive their exten- 
sion, from insanitary conditions, wholly independent of 
destitution. 

The investigation of the causes of typhoid is a more 
complicated question than that of the sources of typhus 
fever. Under the head of predisposing causes, in the 
first place the season of the year is very important, the 
disease always appearing most widely in the autumn, 
and subsiding to its lowest level in the spring and early 
summer. Secondly, the influence of temperature and 
moisture is very strong : it has been noted that a long 
continuance of hot, dry summer weather greatly predis- 
poses to the occurrence of the disease ; and conversely, 
a cold and wet summer and autumn hinder its develop- 
ment. And thirdly, typhoid fever is distinguished by 
4* (41) 



42 NOTES ON EPIDEMICS. 

a characteristic which widely separates its causation 
from that of typhus — namely, that it shows a marked 
preference for young subjects : 52 - 08 per cent, of the 
cases admitted to the London Fever Hospital during a 
period of ten years occurred in persons between the 
ages of fifteen and twenty-five, and only 2*7''76per cent, 
in subjects above the latter age. Whereas typhus is, 
for the most part, a disease of adult age, 53 58 per 
cent, of the cases occurring at ages above twenty-five 
years. 

Of exciting causes, two are recognized as far out- 
weighing in importance all the rest. The first is the 
direct introduction of decomposing organic matters (and 
possibly of organic germs developed from this source) 
into the alimentary canal by the agency of impure 
drinking water; and secondly, the inhalation of the 
gases formed in the decomposition of organic matters, 
and possibly specific germs along with these. Of the 
former mode of origin it is easy to find countless exam- 
ples in the medical history of our country towns, es- 
pecially during the period previous to the adoption of 
deep drainage, and more recently in localities where 
enlightened modern views have not yet availed to force 
this reform on the inhabitants. The following are the 
typical conditions in which typhoid fever arises from 
impurities in drinking-water (we write with a well-re- 
membered instance in our mind). A country town 
without deep drainage disposes of its sewage in cess- 
pools ; and the limited space in which the houses stand 
renders it inevitable that the drinking wells should be 
within a very short distance of the cesspools. From 
the latter a continual oozing of decomposing organic 
matters takes place, and more or less of these finds its 
way into the wells. For years, possibly, no particular 



TYPHOID FEVER. 43 

harm may result from this; but at length there comes 
a long dry summer, which reduces the water to a low 
ebb, and concentrates its impurities, besides favoring 
decomposition; in such circumstances typhoid fever 
breaks out among the persons who drink the water. 

Such is the story which scores of country towns have 
repeated in their own experience. But there is another 
mode of origin for the disease of which we possess ex- 
amples of apparently equal accuracy. A hot, dry sea- 
son favors decomposition, as we have already said : 
under these circumstances sewage gases ascend through 
the imperfect traps of the drains into the interior of the 
houses ; and of this also an outbreak of typhoid is a 
frequent consequence. 

This is the explanation of the genesis of typhoid 
fever which is given by the best authority, probably, 
on the etiology of the disease. The doctrine, which re- 
ceived the name of the Pythogenic theory from its 
author (Dr. Murchison), has met with able and ener- 
getic opponents, foremost among whom must be reck- 
oned Dr. Budd, of Bristol, who has persistently, and 
with great ability, opposed all suggestions of the possi- 
bility, even, of the origin de novo of any epidemic dis- 
ease. But even this authority allows so much as that 
the excretions of typhoid fever patients, by contami- 
nating the soil and the drinking-water, may and do 
cause the indefinite reproduction of the "germs" which 
he supposes necessary to the propagation of the dis- 
ease. In short, all observers arrive at the conclusion 
that it would be possible, by rendering our drinking- 
water absolutely pure, and by disinfecting our sewage 
at the earliest moment, almost or entirely to suppress 
typhoid fever. This is not mere theory; it has been 
verified in the case of Salisbury, a town which was 



44 NOTES ON EPIDEMICS. 

formerly afflicted to a large extent with the disease, but 
has been rendered healthy by the simple adoption of a 
proper drainage system. And although these facts in 
the history of the diseases are most readily and forcibly 
illustrated from the experience of rural districts where 
the main-drainage system has never penetrated; they 
may also be verified by an appeal to the circumstances 
under which typhoid fever still originates in London- 
The cases of the disease which annually (particularly 
in the autumn season) come into the metropolitan hos- 
pitals are furnished, in the immense majority of in- 
stances, from courts and alleys, where the carelessness 
of the inhabitants, or the neglect of landlords, makes 
the water-closets a special nuisance instead of a benefit ; 
or where the mischievous practice of storing drinking- 
water in decaying wooden tubs, which are rarely cleaned 
out, causes that necessary of life to be tainted with de- 
composing organic matter. Occasionally a case or two, 
or a series of cases, make their appearance in a private 
house of the better class; in such instances it will 
usually be found that the drains are in bad condition, 
or the drinking-water unusually foul. Other sources of 
fetid emanations are occasionally found: thus we have 
known a whole family to be made seriously ill, and more 
than one of its members to suffer from unmistakable 
typhoid fever, owing to the decomposition of the dead 
body of a single rat behind a wainscot or beneath a floor. 
In short, the cases are so rare in which the presence 
of putrid organic matter has not been a prominent cir- 
cumstance, that it seems reasonable to suppose that 
this source of mischief was simply overlooked in these 
instances. 

Upon the subject of contagion, with regard to which 
medical opinions were much divided in the early days 



TYPHOID FEVER. 45 

of distinction between typhus and typhoid fever, there 
is now little doubt in the minds of the great majority of 
competent observers. Typhoid fever is not contagious 
in the same sense as typhus is. Our own experience 
enables us to speak with confidence on this point, for 
we have been able to watch very closely the course of 
events both previously to, and during, the present epi- 
demic of typhus which has now infected London con- 
tinuously for the last five years. Typhoid, being a dis- 
ease associated with the general insanitary conditions 
which have always prevailed to a greater or less ex- 
tent, may be said to have been a constant resident in 
London for any number of years ; but typhus has only 
become permanently located there since the great in- 
fluxes of destitute persons which have taken place of 
late years ; formerly it was only an occasional visitor. 
In strict correspondence with this fact was the rarity 
with which nurses in London hospitals contracted fever 
from patients in the wards previously to the commence- 
ment of the present typhus epidemic, contrasted with 
the melancholy frequency of such events during the 
last four or five years. It is true that the attendants on 
typhoid patients do occasionally contract that disease, 
but such occurrences appear to depend upon accidental 
want of care as to exposing themselves to the odors of 
typhoid sewage matters. In country hospitals, where 
typhoid fever constantly presents itself, and typhus 
hardly ever appears, it is very rare for the medical 
officers or nurses to contract fever; in short, all the 
evidence tends strongly to the conclusion that there is 
not, as in the case of typhus, any emanation, from the 
skin and lungs, of an active contagious poison. 

Typhoid fever, in respect of its early symptoms, is 
one of the most insidious and deceptive diseases which 



46 NOTES ON EPIDEMICS. 

exist. A well-marked case is usually ushered in by 
shivering, followed by febrile excitement ; but very 
often it happens that the only noticeable symptoms 
during the first four or five days, or even longer, is the 
occurrence of abdominal pain and diarrhoea, the evacu- 
ations presenting a peculiar color like that of yellow 
ochre, or rather pea-soup. There is great variation in the 
date of the appearance of the characteristic eruption ; 
most commonly it is first seen on the sixth, seventh, or 
eighth day of the illness, but it may first appear several 
days later than this. When once fairly observed (espe- 
cially if it has been preceded or accompanied by diar- 
rhoea and abdominal pain and tenderness) the erup- 
tion is highly distinctive; it consists of small circular 
rose -colored spots, which are almost confined to the 
trunk, and are generally most easily detected in the 
abdomen or the chest ; they vanish on pressure and re- 
turn on its removal, and they present one remarkable 
character, viz., that they appear in successive crops (a 
very few at a time) on successive days. They are not 
much bigger than flea-bites, from which they may be 
distinguished by their disappearing completely on press- 
ure ; flea-bites, on the contrary, when pressed firmly 
with the finger, only diminish in size, but a central 
puncture remains visible. 

It is obvious, from the above description, that a 
patient may be ill for eight or ten days with obscure 
symptoms, which would by no means indicate to an 
ordinary unprofessional observer that so serious a dis- 
ease as typhoid fever had attacked him. Under these 
circumstances it is of the highest importance to obtain 
a simple means of diagnosis, previously to the occur- 
rence of the distinctive eruption, which may put friends 
on their guard. Such an indication is fortunately now 



TYPHOID FEVER. 47 

obtainable by the use of the thermometer. Taking the 
average of cases (Wunderlich and Traube), the ranges 
of temperature are as follows : On the evening of the 
first day the temperature will rise to 100j° Fahrenheit, 
and by the following morning will have fallen to 99J° ; 
on the evening of the second clay it will be 101j°, and 
on the following morning will have sunk to 100^-° ; 
on the evening of the third day it will be 102 J°, and on 
the next morning 101 J° ; on the evening of the fourth 
day 104°, and on the following morning 103j° ; on the 
evening of the fifth day 104^°, and on the next morning 
103° ; on the evening of the sixth clay 104°, and on 
the next morning 102^° ; on the evening of the seventh 
day 103^°, and next morning 102° ; on the evening of 
the eighth day 104°, and on the morning following 
102^°; on the evening of the ninth day 104°, and next 
morning 103° ; on the evening of the tenth day 104^°, 
and the morning after 103°, etc., etc. The above indi- 
cations are enough to substantiate with certainly the 
existence of typhoid fever, when joined with diarrhoea, 
or even simple abdominal pain and tenderness. The 
figures of the successive temperatures may not follow 
exactly the standard we have given ; but they will 
always conform, with greater or less exactness, to this 
order of succession ; and, in particular, the remarkable 
changes which regularly occur between evening and 
morning are highly characteristic of typhoid fever. 
The observation of temperature supplies us with a 
most valuable means of distinction between typhoid 
fever and typhus, in those early stages when as yet no 
eruption is visible. And still more valuable is the use 
of the thermometer in cases, which are by no means 
very unfrequent, in which there is an absence of severe 
external symptoms of fever, and no very remarkable 



48 NOTES ON EPIDEMICS. 

prostration of strength in the early stages. . Not long 
since, a patient was admitted to the London Fever 
Hospital, who died three days afterward. He had suf- 
fered, about a fortnight before, from obscure febrile 
symptoms, which had been made light of, and he had 
returned to his occupation as a laborer. All this time 
the patient had really been suffering from typhoid fever ; 
and the fatal result which ensued arose from a pecu- 
liarity of the disease which must be explained. Typhoid 
fever is accompanied by a characteristic ulceration of 
the mucous membrane of the small intestines. Under 
ordinary circumstances this affection is only developed 
to a comparatively slight extent, and the ulcers readily 
heal again. But it occasionally happens, and is very 
likely to happen when proper precautions as to rest, 
etc. have been neglected, that the ulceration assumes a 
severe type, and the ulcers eat through all the coats of 
the bowel, allowing its contents to escape into the gen- 
eral cavity of the abdomen ; this accident excites in- 
tense inflammation, which almost invariably proves 
quickly fatal. Had the thermometer been employed 
in the early stages of the disease, in the above-related 
case, the serious nature of the affection would have 
been detected, and the unfortunate results very proba- 
bly avoided by the use of suitable precautions. 

The insidious nature of typhoid fever, and the diffi- 
culty which not unfrequently occurs in detecting its 
existence, makes it important that the general public 
should know the principal synonyms under which the 
affection has been spoken of, and which have often dis- 
guised its real nature. In order to appreciate these, our 
readers must be told something of the history of the 
gradual identification of the disease, which has only 
become complete during the last thirty years. The 



TYPHOID FEVER. 49 

name "typhoid fever,'' in its modern limited accepta- 
tion, dates only from that period. The phrase "ty- 
phoid," was formerly applied merely in a general and 
vague manner, to indicate a certain depressed condition 
of the bodily powers, which may be observed in any 
acute disease, just as we speak, even at the present day, 
of a "typhoid" pneumonia (inflammation of the lungs), 
signifying thereby a form of pneumonia attended with 
unusual depression. Typhus and typhoid fever were 
confounded together under the name of "continued 
fever," a term derived from the greater duration of 
these diseases than that of measles, scarlatina, small- 
pox, and other eruptive fevers, in which the specific 
symptoms last only a few days. In this state of medi- 
cal knowledge it cannot be doubted that a vast number 
of cases of typhoid fever — those, namely, in which the 
febrile symptoms were but little marked — escaped recog- 
nition under the vague names of "low fever," "fever on 
the spirits," " gastric fever," "infantile remittent fever," 
and various other uncertain denominations ; this was 
particularly the case with regard to the instances in 
which the patients were young children ; and this kind 
of error is still unfortunately too common. It is only 
in quite recent times that the main features of typhoid 
fever have been so grouped together as to render the 
identification of the disease accurate ; these are, the delay 
of the appearance of the eruption till a week, on the 
average, from the commencement of the febrile symp- 
toms, the peculiar ranges of temperature already al- 
luded to, the duration of the febrile symptoms for about 
three w^eeks (instead of about two weeks, as in typhus), 
the occurrence of inflammation and ulceration of the 
bowels, and a specific diarrhoea, the manner in which 
the rash is developed, in successive crops of spots, and 

5 



50 NOTES ON EPIDEMICS. 

the remarkable absence of severe prostration (as com- 
pared with typhus) in the early stages. 

It would be improper to conclude our notice of the 
symptoms of typhoid fever without some reference to 
a feature of the disease which is of great consequence 
to those concerned in the management of patients during 
convalescence. Non -medical people are apt to greatly 
underrate the serious disturbance of the system which 
is caused by an attack of typhoid, and the slow way in 
which convalescence is established. In the first place, 
the ulcerative affection of the intestines is frequently a 
source of danger, long after the febrile symptoms have 
apparently come to an end, and unless great care be 
taken to enforce perfect rest, and the avoidance of irri- 
tation of the intestines by unsuitable food, etc., it may 
take a dangerous and even fatal course. Secondly, 
there is a marked tendency to the occurrence of inflam- 
matory diseases of the lungs, as a sequel to the fever. 
Thirdly, in persons predisposed to consumption, this 
malady is not unfrequently evoked by typhoid into an 
activity which it might otherwise never have assumed. 
Fourthly, a peculiar condition of the brain often remains 
for some time after the fever, in which there is a tend- 
ency to a semi-delirium or even to fatuousness, and 
the mental equilibrium is in considerable danger of per- 
manent impairment. These and various other unfor- 
tunate sequels of the disease are so readily produced, 
that the best authorities have arrived at an opinion 
which is succinctly expressed by Dr. Aitken : " No man 
can be considered as fit for work, or for general mili- 
tary service, for three or four months after an attack of 
severe typhoid fever." 






CHOLERA. 51 

Cholera. — We have spoken with much, and we be- 
lieve well grounded, confidence of the causation, or at 
least the principal modes of propagation, of typhoid 
fever. It is hardly necessary to say that of cholera, 
which we have included in the same group of epidemic 
diseases, it is impossible to speak with any such ap- 
proach to certainty. No doubt the disease is still an 
opprobrium medicinse. Yet something seems to have 
been really learned, not merely guessed, about this 
mysterious pestilence, in recent years, and fortunately 
our modern knowledge is of that useful kind which 
suggests new and promising researches. 

The problems of causation which present themselves 
for solution in the case of genuine cholera are doubtless 
highly complex. Yet, be it said at once, they are 
decidedly less intricate than those which concern the 
origin of several epidemics which are far more frequent 
visitors of European countries, and which cause a far 
larger aggregate of mortality. Such facts ought to 
shame us from our habits of panic, and inspire us with 
a hopeful interest in the investigation of cholera. 

The first question which comes up for investigation 
is that of the place of origin of the disease. Many 
circumstances undoubtedly point to the East, and espe- 
cially India, as the original focus of cholera ; and it was 
the fashion, not very long since, to speak of the delta 
of the Ganges as the first home of the pestilence. 
There can be no doubt that the mouths of slowly run- 
ning rivers, where large accumulations of decaying 
organic matter swelter beneath a tropical sun, offer 
many of the recognized conditions for the outbreak of 
epidemic diseases. But an impartial study of the 
records of ancient and medieval medicine makes it 
doubtful whether cholera has not periodically prevailed 



52 NOTES ON EPIDEMICS. 

in Europe from the earliest times ; and the most that a 
cautious reasoner would now affirm is, that only Asiatic 
countries at present seem to possess the conditions for 
the development of cholera in such force as may suffice 
to send the epidemic wave rolling across the world. 
The question of the possible origin of cholera de novo 
must be left open ; at the same time it is proper to men- 
tion, that one of the ablest of Indian observers, Dr. 
Barnes, gives very strong testimony to the occurrence 
of an outbreak, under his own eyes, in Jessore (Ben- 
gal), the spontaneous generation of which, from the 
exhalations arising from the decomposition of animal 
and vegetable matter, and the use of drinking water in 
which this process was continually going on, seemed 
incontestable. 

With regard to the effect of atmospheric influences 
there has always been a great conflict of opinions ; but 
this subject is probably summed up with justice in the 
able treatise of Dr. Goodeve. A high temperature,* 
combined with moisture, especially when the air is 
stagnant or moving but slowly, appears to increase the 
intensity of the disease ; but no such combination has 
ever been proved to have determined the occurrence of 
an outbreak. And conversely, though cholera has fre- 
quently been checked by winter cold, it does not seem 
in any case to have been destroyed by this agency. 
" Neither climate, nor season, nor earth, nor ocean seem 
to have arrested its course, or to have altered its fea- 
tures. It was equally destructive at St. Petersburg 
and Moscow as it was in India; as fierce and irresisti- 

* It would perhaps be more correct to say a trojncal temperature. 
Pettenkofer, a very high authority, was so impressed by his own ob- 
servations of the epidemic in Munich, in 1854, that he was led to 
deny the influence of temperature in tuto. 



CHOLERA. 53 

ble among the snows of Russia as in the sunburnt re- 
gions of India; as destructive in the vapory districts 
of Burmah as in the parched provinces of Hindostan." 
(Goodeve.) Again, impurity of the atmosphere has 
been frequently observed to promote the severity of 
cholera, but, on the other hand, it is found that in many 
epidemics some very foul and filthy places escape alto- 
gether. The most that can be said is that "the places 
in which the air is most vitiated from drains, decaying 
animal matter, and vegetable refuse, or overcrowding 
and concentration of human emanations, are those in 
which cholera has generally been most fatal and most 
widely spread." (Goodeve.) But these facts, and also 
the circumtance that the disease affects places whose 
level is low, and especially the banks of rivers, are sus- 
ceptible of at least a possible explanation of a different 
kind. 

It is, in fact, when we turn to the investigation of 
quite another kind of local circumstances, that we get, 
not a full illumination, but some scattered rays of light 
upon the causes of the spread, at least, of cholera. The 
possibility of the communication of the disease by the 
contamination of drinking water with organic impuri- 
ties, was long ago noted by various observers ; but it 
was reserved for the late Dr. Snow to furnish by far the 
most important evidence in this direction. The year 
1854 was made memorable in the annals of medical 
science by the remarkable outbreak of cholera in the 
parish of St. James, Westminster. The disease had 
already announced its presence by the occurrence of a 
few cases during the later months of 1853 ; but the 
number of attacks declined, in the two first quarters of 
1854, to a very low ebb ; at the end of June, however, 
they began to increase, till, in the last week of Sep- 

5* 



54 NOTES ON EPIDEMICS. 

tember, the cholera mortality reached 2050. In the 
parish of St. James, the first fatal case for the year 
1854 happened at the end of July; but there was only 
a dropping fire, as it were, which kept within quite 
moderate limits up to the last days of August, when 
suddenly the disease made an enormous explosion in 
the district. In the most crowded part of this densely 
crowded parish there occurred, on the thirty- first of 
August, no less than thirty-one fatal cases, all within 
an extremely narrow area ; on the following day there 
were 131 fatal cases in the same area; on the 2d of 
September, 125 ; on the 3d, 58 ; on the 4th, .52; on the 
5th, 26; on the 6th, 28; on the Tth, 22; on the 8th, 
14 fatal attacks, all in the same space, which might be 
marked off by a circle whose center should be at the 
junction of Broad Street and Cambridge Street (Soho), 
and whose radius would be of the length of 210 yards. 
From the last of these dates the disease rapidly dimin- 
ished to a comparatively insignificant level, and may 
be said to have ceased by the end of October. Such a 
phenomenon as this was unusual in our English ex- 
perience of cholera ; and the very singularity of the 
outbreak inspired Dr. Snow with the hope that fresh 
light would be thrown by it on the whole question of 
cholera propagation. Fixing his attention steadily on 
the local peculiarities of the district, Dr. Snow quickly 
perceived that one remarkable circumstance was com- 
mon to the history of the large majority of attacks of 
the disease, viz., that the sufferers had been in the habit 
of drinking the water of a well in Broad Street, which 
had a great reputation for sweetness and freshness. 
Analysis of this water soon showed that it was highly 
charged with organic impurities ; and on the eighth of 
September, the vestry, on the urgent persuasion of Dr. 



CHOLERA. 55 

Snow, removed the handle of the pump, and so pre- 
vented the further use of the well. On subsequent ex- 
amination it was discovered that the sewage from a 
neighboring house-drain had leaked into the well, and 
it was, moreover, shown that the discharges of a patient 
residing in the house in question, and suffering from 
severe diarrhoea, if not from actual cholera, must have 
mingled with the sewage immediately before the date 
of the great epidemic outbreak. 

The history of this epidemic, taken in connection 
with analogous but less striking facts which had been 
before observed, afforded strong suggestions, if not 
proof, of the important part which impure drinking 
water might play in the propagation of cholera, and the 
matter was by no means allowed to rest there. An 
examination of the circumstances of cholera-develop- 
ment among the inmates of the houses supplied with 
water by the Lambeth Water Company and Southwark 
and Yauxhall Company respectively, displayed the re- 
markable fact that the ratio of mortality from cholera 
was three and a half times as great in the former in- 
stance as in the latter; and an analysis of the waters 
of the two companies showed a corresponding differ- 
ence in freedom from organic impurities. The case 
was rendered the more striking by the fact that the 
two companies to a large extent served the same gen- 
eral district, so that in many instances the impure water 
supply and the high mortality were noticed on one side 
of a street, in contrast with the purer water and the 
lessened mortality in the houses actually opposite. 

The inferences which may be drawn from the great 
mass of facts which has now been arrayed by various 
observers, in favor of the influence of impure drinking 
water in the propagation of cholera, must not be over- 



5G NOTES ON EPIDEMICS. 

rated. We can afford to pass, without much comment, 
the adverse conclusion of the Reporter to the Cholera 
Committee of the Royal College of Physicians in 1854, 
since the writer was not in possession of the remarkable 
evidence arising out of the investigation, by Dr. Snow 
and others, of the circumstances of the outbreak in St. 
James's, Westminster. The adverse testimony of Pro- 
fessor Pettenkofer, of Munich, is of far greater import- 
ance, both from the deserved weight attaching to the 
opinions of an extraordinarily able observer, who had 
enjoyed extensive opportunities of investigating the 
subject, and also because the professor advances obser- 
vations and a theory of his own which bear forcibly on 
the part which excremental impurities may play in the 
spread of cholera. In the first place, Pettenkofer's ob- 
servations appear to prove decidedly that the drinking 
water had no considerable share in the propagation of 
cholera in the epidemic at Munich. But they further 
demonstrate, very clearly, that the situation of houses 
on a porous soil of any kind insured a greatly increased 
rapidity and energy of diffusion of the disease ; while 
rocky foundations afforded a very remarkable protection 
from the same. Pettenkofer was convinced, by ample 
evidence, that the penetration of the soil by the dis- 
charges of cholera patients was the first essential link 
in the chain of propagation, and the coincidence of this 
part of his theory with Snow's affords a strong support 
to it. The further stage, however, was considered by 
the Bavarian professor to consist, not in the defilement 
of the drinking water, but in the formation of a mias- 
matic vapor from the decomposing matters, which 
vapor conveyed the poison, by inhalation, to the lungs 
of the inhabitants of the houses. 

There appears to us to be no reason for rejecting 



CHOLERA. 51 

either theory ; and as far as regards the propagation of 
cholera in a place which has once become infected, we 
feel that the united testimony of the two observers 
gives enormous w T eight to the belief that the leakage of 
sewage matters through a spongy soil is the point of 
departure in the process; while, quite possibly, both 
drinking-water and sewage- gas may become the car- 
riers of the poison to the human body. It is obvious, 
too, that a circumstance to which great force was 
given, in the report of the Registrar-General on the 
cholera mortality in 1848-9 — the effect, namely, of com- 
parative elevation of a site in decreasing the ratio of 
its liability — ma}^ be interpreted as an indirect confirm- 
ation of the disastrous effects of sewage contamination, 
seeing that the lowest sites are necessarily the worst 
drained. Still more susceptible of such an interpreta- 
tion is the fact, which was clearly demonstrated by 
the Registrar- General, that the spread and fatality of 
cholera are directly increased by augmented density of 
population. In short, there appears to be sufficient 
ground for a very strong belief that the prevention 
of sewage-leaking, which is accomplished wherever a 
proper deep drainage is carried out, strikes a fatal blow 
at the most powerful medium of cholera-diffusion. 

Of contagiousness, as that word is understood in the 
case of such diseases as typhus, or small-pox, or scarlet 
fever, cholera seems to have little or nothing; the con- 
currence on this point of Snow, Pettenkofer, Goodeve, 
and the great majority of the Indian practitioners, is 
sufficient to settle that question to our minds, even 
though a considerable number of the adversaries still 
hold to their opinion. Moreover, certain disagreeable 
explanations by Snow, of the manner in which infec- 
tion may be caused by swallowed impurities derived in 



58 NOTES ON EPIDEMICS. 

other ways than through drinking-water, appear to 
amply satisfy the requirements of those cases which 
cannot be explained by the water-theory or by the 
miasm-theory. 

The mode of transit of cholera from one place to 
another is a very interesting subject. There can be 
no doubt that, in the majority of cases, the march of 
the disease follows closely the lines of most frequent 
human communication : thus it always appears first, in 
any country, at the seaport towns, and these places 
form the first centers of infection. It may be tracked, 
by this sort of route, all the way from India, in each of 
the three great epidemics (of 1831, 1848-9, and 1854), 
which have visited this country. On the other hand, 
there are cases in which the spread of cholera across 
the sea, or across great districts of land, seems to have 
happened without human communication : the instance 
of the island of St. Kilda, Western Scotland, is re- 
markable in this way, for there seems to have been 
a complete absence of any possibility of human inter- 
course with the main land. Indeed, so many analogous 
cases have been recorded, that Dr. Goodeve comes to 
the conclusion, that "it is indisputable that cholera 
originates in places without its being possible to trace 
any previous communication with infected persons." 
These facts are of course explicable on different hy- 
potheses. Either the outbreaks which occur in this 
remarkable way may be instances of the generation of 
cholera de novo, from insanitary conditions prevalent 
on the spot, or we may suppose the poison to have 
been carried by currents of wind. In favor of the 
former theory, there are certain facts of much interest : 
thus, at Coventry, in 1838, an extraordinary outbreak 
of true Asiatic cholera occurred in the House of In- 



CHOLERA. 59 

dustry, in the middle of winter, at a time when cholera 
was not prevailing in the country; fifty-five of the in- 
mates perished very quickly. On the other hand, the 
theory that cholera is disseminated by an air-borne 
poison, or that the virus is, at least, occasionally dif- 
fused in this way, finds many respectable supporters ; 
and there are some remarkable facts which seem to 
confirm this idea. Thus, Dr. Parkes relates that "at 
Madras the disease was heard of at a station ninety 
miles off; a few days afterward it appeared in Madras 
itself. And a wind blew directly from the station in 
which the disease had shortly before been prevalent." 
There is some reason to think that cholera spread from 
Armagh to Belfast, in the year 1848, by the agency of 
a strong wind, which blew directly from the former to 
the latter place for nearly a whole day. And at Sund- 
erland, in the same year, the first case on shore oc- 
curred in a house which was situated directly to lee- 
ward of some infected ships, while a strong east wind 
was blowing over the latter. There are several similar 
cases on record; but it must be allowed, on the whole, 
that they are too few in number, not to be open to 
much suspicion of fallacy in observation. 

Supposing the poison to be air- borne, or to be capa- 
ble of this mode of transit, there are still two further 
suppositions which are open to us. We may suppose 
the virus to consist of a simple material substance ; and 
in that case there is more probability of its being really 
a kind of microscopic fungus than anything else. Or 
we may select the theory to which Dr. Goodeve seems 
to incline: namely, that the infection maybe air-borne, 
but that it needs, for its development, to meet with a 
peculiar local element with which it may combine. On 
the whole, the practical conclusion which seems most 



60 NOTES ON EPIDEMICS. 

consonant with all the facts, as to the propagation of 
cholera, is that, in the great majority of instances, the 
communication of the disease takes place by human 
means ; and by the infection of a locality, in the man- 
ner described by Snow, or else in that supposed by 
Pettenkofer. Accepting either, or both, of these modes 
of multiplication of the poison, we leave open the possi- 
bility that the poison is really of the nature of a fungus, 
or some other low cellular organism ; and this latter 
hypothesis would undoubtedly possess the convenience 
of agreeing well with the possibility of occasional trans- 
mission by winds. 

The premonitory symptoms of cholera are few and 
vague in character. A certain number of patients 
suffer from giddiness, noises in the ears, etc. for some 
hours before the outbreak of distinctive symptoms ; 
but the majority are not conscious of anything wrong 
till diarrhoea or some other special symptom suddenly 
occurs. The diarrhoea may commence as ordinary re- 
laxation of the bowels, only more severe than the com- 
mon forms of that affection ; but very soon, in the great 
majority of cases, the discharges become extrernety fre- 
quent, and very colorless and watery, and they present 
an appearance of being filled with white flakes, which 
give them a look resembling that of rice-water. The 
central and essential feature of all cases of true cholera 
is the occurrence of a peculiar state of collapse, which 
comes on after a few hours, or even in a shorter time, 
from the first morbid symptoms; this collapse is in- 
dicated by a deadly coldness, and a livid paleness of 
the surface of the body, total loss of muscular strength, 
coldness of the breath, voice reduced to a whisper, and 
an entire suppression of the urinary secretion ; usually, 
also, there are severe cramp-like pains in the abdomen 



CHOLERA. 61 

and limbs. The intellect retains a remarkable clear- 
ness even to the last ; there is a complete calmness of 
mind, an entire absence of emotion at the prospect of 
death ; and patients will often dictate, without the least 
appearance of agitation, minute and important direc- 
tions respecting the disposal of their property, etc. It 
is a noteworthy circumstance that, in a good many of 
the severest and most rapidly fatal cases, there has 
been, from first to last, a complete absence of diarrhoea ; 
this fact has been held by many observers, and rightly 
so in our opinion, to prove that the intestinal affection 
is not the primary or essential feature of the disease. 
This is a matter of the greatest consequence, not merely 
as regards the medical treatment of cholera, but because 
the opposite opinion naturally leads to a too great re- 
liance by the public on the efficacy of medicines calcu- 
lated to check diarrhoea. There has been, and there 
still is, a great tendency to imagine that cholera is ordi- 
narily the sequel of neglected common relaxation of the 
bowels, and that a timely suppression of the latter 
symptom would save the patient ; but we are bound 
to say that there seems to be but little evidence which 
is of any worth in favor of this view. As positive evi- 
dence in the contrary direction, we may mention the 
testimony lately given to us by a medical friend, who 
had very ample opportunities, as a parish surgeon, of 
watching the dreadful outbreak of cholera in one of the 
most crowded London districts, during the year 1854, 
is most unequivocally opposed to this idea. This gen- 
tleman asserts that he witnessed, over and over again, 
cases of common autumnal diarrhoea treated by the 
ordinary remedies for that complaint with success ; 
but cholera nevertheless supervened shortly afterward, 
and proved fatal. A very large number of cases of 

6 



62 NOTES ON EPIDEMICS. 

cholera also occurred quite suddenly without any pre- 
liminary stage of common diarrhoea. The inference 
suggested by these facts is by no means that symptoms 
of what seems ordinary diarrhoea, occurring at a time 
when cholera is prevalent, should be neglected, or re- 
garded as trivial ; but simply that medical advice should 
be sought at the very earliest period, and that no confi- 
dence should be reposed in home remedies, administered 
with a view to checking an attack of diarrhoea. 

Epidemic Diarrhoea. — We pass, now, to the consid- 
eration of another disease, closely bound up with chol- 
era, and standing in a most important relation to its 
development, which must be briefly sketched, — we refer 
to epidemic diarrhoea, or " English cholera." 

Epidemic diarrhoea is the constant product, in this 
country, of autumnal seasons which succeed to a long 
continuance of hot, dry summer weather. It is now 
well established that this affection is caused by the 
effluvia from decomposing organic matter, or by the 
admixture of such impurities with drinking water ; hence 
its special prevalence at seasons when the temperature 
has occasioned a reduction in the volume of rivers, 
springs, etc. and at the same time hastened the putre- 
faction of organic matters which they may hold in solu- 
tion. These facts being now well ascertained, are of 
the highest interest in regard to the constant relation 
which exists between the development of epidemic 
diarrhoea, and the liability to outbreaks of true Asiatic 
cholera : this relation is established in the clearest man- 
ner by the records of disease and mortality for the 
great cholera years. Thus, for the two years previous 
to the outbreak of cholera in 1848, there had been a 
progressive increase in the amount of epidemic diar- 
rhoea, and the latter affection raged with great violence, 



EPIDEMIC DIARRHOEA, 63 

during the progress of the more serious disease, in 1848 
and 1 849. Similar facts were conspicuous in the history 
of the cholera epidemic of 1854 ; and during last autumn 
scarcely any physician would have denied that the in- 
crease of diarrhoea was by far the most serious omen 
in regard to the probability of an extension of the 
"Asiatic" malady to our shores. It is a mistake to 
suppose that ordinary years witness no true cases of 
the more formidable disease in England : on the con- 
trary, a year never passes without the occurrence, dur- 
ing the diarrhoea season, of a few deaths from diar- 
rhoeal affections which assume all the characteristics of 
genuine cholera. In short, the connection between epi- 
demic cholera and epidemic diarrhoea is so close, that 
although we cannot suppose the one to be a mere ag- 
gravated form of the other, we may almost venture to 
affirm that, if once the insanitary conditions which bring 
about the occurrence of the latter disease were removed, 
the former could hardly prevail with any serious in- 
tensity. 

Under the heading of epidemic diarrhoea we may 
properly include an affection which really belongs to 
the same class, though its common appellation, and 
some of the anatomical changes which have been ob- 
served to attend it, have led to its being confounded 
with a tropical epidemic disease, which is of a very dif- 
ferent nature. We refer to the so-called "Dysentery," 
which is occasionally observed in the inhabitants of 
Great Britain, and which was formerly a very fatal 
disease in this country. 

The true tropical dysentery is a specific and very in- 
teresting disease, having intimate though not accurately 
ascertained relations with the more severe intermittent 
and remittent fevers. Its British pseudo-representative 



64 NOTES ON EPIDEMICS. 

resembles it in so far as regards the intestinal symp- 
toms, which consist of a bloody and mucous flux from 
the bowel, recurring in small quantities at very short 
intervals, and attended with great straining and dis- 
tress; and, after death, in the extremely rare fatal 
cases which happen in this country, there is discovered 
more or less of the same inflammation and ulceration of 
the large intestines which distinguishes the tropical 
complaint. But British dysentery resembles British 
diarrhoea in bearing every degree and variety of signi- 
ficance according to the circumstances under which it 
originates. Common diarrhoea, for instance, may be a 
mere symptom of irritation in the bowels, which may 
arise from a score of different causes, none of which are 
connected with the action of a specific blood-poison ; 
and, in the same way, dysenteric diarrhoea may be 
caused by numerous sources of intestinal irritation. It 
is only when either diarrhoea or dysentery occur under 
the conditions which have been described as favoring 
the propagation of the class of diseases which form the 
subject of this chapter that they assume the epidemic 
type in temperate climates. Two very interesting ex- 
amples may be cited here of the kind of pseudo-dysen- 
tery which is capable of being generated by the bad 
influence of the vapors arising from decaying organic 
matter. The first is one which occurred during last 
year at a lunatic asylum : this establishment was sur- 
rounded by fields the cultivation of which formed an 
interesting and very valuable occupation for many of 
the unfortunate inmates of the asylum. It was de- 
termined to test upon these fields the value of liquid 
sewage as a fertilizing manure, and, accordingly, large 
quantities of the sewage matters supplied by the house 
were applied to this economic purpose. Unfortunately, 



DISINFECTION. €5 

it happened that a part of the ground so treated lay 
very near to the windows of the asylum, and the wind 
carried the gases from the decomposing organic matters 
into the house: the result was an outbreak of very 
severe and fatal dysenteric diarrhoea. It was immedi- 
ately pointed out by various medical men that all this 
mischief might have been avoided by disinfecting the 
sewage matters before discharging them on the land; 
meantime the harm had been done. Another instance 
of the power of putrescent organic matters to produce 
a dysenteric diarrhoea is found in the history of the 
Xewington Workhouse. This establishment was one 
of the last places in London to share in the benefits of 
the main drainage system, and up to a comparatively re- 
cent period a very large, open, tidal sewer, which stank 
offensively in hot and dry weather, ran close under its 
walls. The records of several years of the medical his- 
tory of the workhouse, which were kindly furnished by 
Dr. Iliff, the medical officer of health to the vestry, show 
that diarrhoea and so-called dysentery had frequently 
occurred among the workhouse inmates, under such 
circumstances as left no doubt that the effluvia of the 
open sewer had been the active cause of mischief. 

Disinfection. — In concluding this chapter we must 
refer to the subject of disinfection. The diseases of 
which we have been treating certainly owe their pro- 
pagation chiefly to sewer gases in the air, and sewage 
matters mixed with food or drink; and, although a 
radical preventive treatment would require those meas- 
ures of precaution against the admission of impurities 
which we have already described, nevertheless there is 
much to be done in mitigation of the evils which such 
impurities cause, by means of disinfecting agents. 
6* 



66 NOTES ON EPIDEMICS. 

We shall speak, seriatim, of the measures to be 
adopted for disinfecting: (a) drinking-water, (b) the 
air of rooms, (c) the linen and other articles of clothing 
which may have come in contact with infecting dis- 
charges, (d) the discharges themselves. 

a. Drinking-water is to be disinfected bj the pro- 
cesses of boiling and filtration. The water being first 
boiled, is afterward to be filtered through charcoal; 
filters of this kind are easily obtainable, and the neglect 
of their use is unpardonable when there is the slightest 
reason to believe that there is a possibility of the water 
being contaminated by decaying organic matter, b. The 
air of rooms cannot be purified without, in the first 
place, establishing the freest ventilation. But, in addi- 
tion to this, it is desirable to provide a highly volatile 
disinfectant, which shall penetrate to every nook and 
corner of the apartment ; and for this purpose there is 
nothing better than carbolic acid. Little wooden boxes 
should be placed in different parts of the room, contain- 
ing the carbolic acid, their lids being fitted with a per- 
forated zinc plate, through which the vapors may 
escape, c. Clothes, bedding, etc., which have been 
soiled with infecting discharges, if incapable of being 
washed, may be exposed in an oven, for two or three 
hours, to a heat of 212° Fahrenheit. Linen and other 
things which can be washed should be first boiled in 
water for two or three hours, and then soaked for some 
time in water containing one-fiftieth part of Condy's 
red disinfecting solution.* d. The discharges of patients 



* Condy's fluid is a solution of permanganate of potash in water. 
A good disinfecting liquid can be made by dissolving one drachm of 
the permanganate of potash in a quart of water. The salt in question 
is undoubtedly the best known disinfectant for nearly all purposes. — 
Am. Ed. 



DISINFECTION. GT 

should always, when this is practicable, be received in 
a vessel containing water strongly impregnated with 
Condy's red fluid. Drains and closets which smell 
badly should be purified by frequently throwing down 
them Condy's fluid, diluted with twenty or thirty parts 
of water. And where it becomes necessary, as a pre- 
cautionary measure, to empty cesspools or privies, it is 
important to disinfect the sewage matters by the free 
use of Condy's solution, and the air by means of car- 
bolic acid, or by burning sulphur; the disinfectant pro- 
cess being kept up as long as the slightest sewage smell 
is perceptible. 

But the defensive measure which, more than any 
other, is important for those who attend upon the sick, 
is the precaution of never eating food with hands which 
have not first been washed in water impregnated with 
a disinfectant, such as chloride of lime, or Condy's red 
fluid. 



CHAPTER IV. 
INFECTIOUS EPIDEMIC DISEASES 

WHICH ARE COMPARATIVELY INDEPENDENT OF DEFEC- 
TIVE SANITARY ARRANGEMENTS. 

In speaking of the causal conditions, so far as they 
are known, of our two first groups of epidemic diseases, 
we have been traveling over ground which is compara- 
tively firm beneath our feet. It is far otherwise when 
we pass to the consideration of our third class, under 
which we include scarlet fever, diphtheria, measles, 
whooping-cough, and influenza. It must be fairly 
owned that our faith in the possibility of an ultimate 
extinction of epidemic diseases by preventive measures 
is subjected to a considerable strain, when we contem- 
plate the seemingly capricious and incomprehensible 
ravages of these maladies. Far more justly do they 
deserve the name of modern plagues than does the chol- 
era ; for not only are they fearfully destructive of human 
life, but their mode of origin and outbreak is wrapped 
in what appears to be almost impenetrable mystery; 
and their prevention seems for the present to be nearly 
impossible. 

Scarlet Fever. — This general statement needs, per- 
haps, some modification as far as regards scarlet fever.* 

* Or "scarlatina." This word has, by a common mistake, been 
supposed to mean a different disease from scarlet fever, but the two 
are identical. 

(68) 



SCARLET FEVER. 69 

The generally unhealthy influences of dirt, impure air, 
foul drinking-water, overcrowding, etc. (which are 
known to increase the virulence of all epidemic dis- 
eases), have in some instances been noticed to give a 
particularly strong impulse to the propagation of this 
fever. But in the present state of our knowledge the 
disease must be held to be separated by wide distinc- 
tions, both from the type which is most conspicuously 
represented by typhoid fever, and from that which is 
characteristic of relapsing fever and typhus. 

We have no knowledge whatever of the origin of 
scarlet fever de novo. It contests with small- pox the 
evil distinction of being the most virulently contagious 
disease in existence. There is no need to have direct 
contact with the body of the infected person, or to 
swallow matters contaminated by his secretions— there 
is no necessity even to be in the same room with him, 
in order to contract the disease ; the poison diffuses it- 
self with the utmost rapidity through the atmosphere 
of a whole house, and no single inmate is safe unless 
he is already " protected." This phrase refers to a 
peculiarity which scarlet fever possesses, in common 
with small-pox, typhus, and some other contagious dis- 
eases; namely, that it rarely attacks an individual who 
has suffered from it before. Partly in consequence of 
this, but probably also for other reasons not so clearly 
known, it happens that young children are greatly more 
susceptible of the infection than adults : something like 
68 per cent, of the total mortality occurring in subjects 
under five years of age, and about 24 per cent, more in 
children between five and ten years old. There is some- 
thing appalling in the malignity of infection which dis- 
tinguishes scarlet fever ; not only does it spread with 
fatal celerity through whole households, but the poison 



10 NOTES ON EPIDEMICS. 

adheres with great tenacity to everything it touches, so 
that the walls of rooms in the infected house, and the 
clothes, not merely of the patient, but even sometimes 
of those around him, obstinately retain a contagious 
power. There is considerable reason for thinking that 
the agency of this diffusion of the disease consists in a 
peeling of the outer skin which accompanies convales- 
cence ; the scales of dead epithelium are broken down 
into a minute dust, each particle of which is perhaps 
charged with the poison. It is, at least, notorious that 
patients are immensely more apt to give the disease to 
others, during the period of "desquamation," as it is 
called, than in the early stages; and it is certain that 
in bright sunlight a cloud of fine dust may be seen to 
arise from the body, especially at this period, if the 
clothes be suddenly withdrawn. Supposing this epithe- 
lial dust to be the main agent of infection, there is no 
need to search any further for the cause of that intense 
activity of propagation which characterizes scarlet fever. 
But the singularity of the disease is even more strik- 
ingly evident in the length of time during which in- 
fected articles of clothing, furniture, etc. may retain 
their noxious properties ; even at the end of twelve or 
eighteen months such objects have been known to com- 
municate infection ! 

Such facts might far better justify a panic — if panics 
were ever justifiable — than the threatened return of 
cholera to England ; for scarlet fever is always at our 
doors, and numerous chances expose each household of 
young children to the possibility of a fatal invasion by 
it. And yet out of this evil, as from every other, there 
has come good ; for the one measure which, far beyond 
all others, has been found to practically mitigate the 
virulence of scarlet-fever contagion is ventilation, and 



SCARLET FEVER. 11 

the remarkable influence which it exerts in this case 
has done much to direct attention to its importance in 
the treatment of other zymotic diseases. It is obvious, 
from what we have already said, that in the case of 
scarlatina attacking a member of any household, the 
sick-room must for safety be ventilated in such a man- 
ner as shall insure a copious and continuous supply of 
fresh air ; and that all unnecessary furniture (particu- 
larly curtains, carpets, and other woolen stuffs) should 
be done away with ; the apartment being kept warm 
by means of a good open fire, unless the weather be 
very hot indeed. Far more than in the case of typhus, 
or any other infectious disease except small-pox, is it 
necessary that the clothing, bedding, etc. used by the 
patient, should be scrupulously disinfected by the appli- 
cation of a very high temperature and the use of disin- 
fecting solutions, and that walls, ceilings, and wood- 
work should be freshly limewashed, and painted or 
papered. But no known precautions can make a house 
in which scarlatina has appeared, absolutely free from 
infectious properties till a considerable time has elapsed. 
The early symptoms of scarlet fever are usually dis- 
tinctive. In the majority of cases there is a distinct 
period of latency between the exposure to infection and 
the occurrence of any signs of illness ; but the length 
of this period may vary from one to several days, and 
may even occupy but a few hours. A shivering fit is 
usually the first symptom, and this is followed by fever- 
ish heat, which steadily increases. The skin feels pun- 
gently hot to the hand, and the thermometer marks a 
temperature of 105°, or sometimes much higher. Oc- 
casionally there is severe vomiting, and there is always 
a great sense of oppression and headache previously to 
the appearance of the eruption. The latter event takes 



?2 NOTES ON EPIDEMICS. 

place from twenty-four to thirty-six hours after the com- 
mencement of the symptoms. The eruption first appears 
as a multitude of minute brilliant-red points scattered 
thickly over the skin, and giving a sense of roughness 
to the touch. Very soon, however, they so far run 
together as to give the appearance of a uniform red 
blush, which is commonly compared to the color of a 
boiled lobster. At the same time as the eruption is 
appearing on the skin, changes are going on in the 
mucous membrane of the mouth and throat. The 
tongue is at first covered with a thick white far, 
through which a number of red papillae stand up ; 
these red points are most numerous toward the tip, 
and give the appearance called "strawberry tongue." 
In a few hours later the white fur has disappeared, and 
the whole tongue is brilliantly red, and rough ; the red- 
ness extends also to the back of the mouth, spreading 
over the tonsils and soft palate. A painful soreness of 
the throat is noticed, and actual ulcers are found on 
inspection. The appearance of the skin eruption is 
usually signalized by great relief to the sensations of 
general distress and discomfort; but the temperature 
commonly goes on rising for a day, and sometimes two 
days, after the first occurrence of the skin affection. 

There are cases, however, in which the very char- 
acteristic train of symptoms above described is by no 
means present. It may happen, for instance, that the 
rash never appears at all ; or there may be, from first 
to last, no sore throat. Or, again, in cases where the 
infection is very intense and concentrated, it sometimes 
happens that the patient sinks into a state of profound 
nervous prostration, usually accompanied with stupor, 
and dies, between the first occurrence of symptoms and 
the period at which the eruption might have been ex- 



SCARLET FEVER 73 

pected to appear — fairly crushed, as it were, with the 
force of the poisonous impression on the system. Or 
it may happen that the system has just strength to sur- 
vive the eruptive crisis, but the eruption, instead of 
being bright-red colored, may be dusky or livid in hue, 
indicating failing powers of circulation. Or, finally, the 
throat affection may altogether outweigh all the other 
symptoms in importance ; the throat may be so severely 
ulcerated from an early period as to become a source of 
danger to life ; and this has even happened, now and 
then, in cases where no skin eruption has ever ap- 
peared. These important possibilities of variation 
plainly prove the value of a test like that of the ther- 
mometer, which in either of these anomalous conditions 
would still have proved the existence of febrile disturb- 
ance so severe as to call for the advice of a medical 
man. Another symptom which is of serious import in 
a case where there is any possibility of scarlatina infec- 
tion having been induced is the occurrence of dropsy ; 
especially when this is combined with a sudden sup- 
pression or great reduction of the urinary secretion, or 
the appearance of a smoky color in the urine. The 
scarlatinal poison has a great tendency to affect the 
kidneys ; and the last-named symptoms are an indica- 
tion that this very dangerous affection has actually 
occurred. 

A word must be said as to the appearance of the 
throat in those cases where the throat affection is a 
conspicuous symptom. However severe the inflam- 
matory and ulcerative changes in this part may be, 
they are usually distinguishable from those which 
occur in diphtheria by the non-occurrence of a " false 
membrane," such as we shall have to describe when we 
treat of the latter disease. The appearances are those 

7 



T4 NOTES ON EPIDEMICS. 

of low inflammation and ulceration. Still it is by no 
means always possible, even for a medical observer, to 
distinguish between the two diseases by a mere inspec- 
tion of the throat; the general character of the symp- 
toms, and especially the comparative absence of febrile 
heat (as measured by the thermometer) in the case of 
diphtheria, is more distinctive. But, in the case of 
scarlatina, the thermometer, at any rate, will give in- 
dications, even at an early stage, and before the appear- 
ance of the eruption, which ought to lead to the imme- 
diate summoning of medical assistance. 

Diphtheria. — If we are in the dark about the origin 
of scarlet fever, we are still more in doubt as to the 
original causes of diphtheria. The disease has doubt- 
less prevailed epidemically, at intervals, from the earliest 
times of which we possess any medical records ; but the 
general recognition of its characters, as distinguished 
from those of common inflammatory croup and some 
other diseases which superficially resemble it, has only 
taken place within the present century. As with scarlet 
fever, so in the case of diphtheria, we have no knowl- 
edge of an origin de novo; contagion has always ap- 
peared to be the cause of the outbreaks which have 
occurred of late years : but the contagion is of a highly 
peculiar and obscure kind. The poison resembles that 
of scarlatina in adhering obstinately to the walls or 
furniture of houses ; but it is essentially devoid of the 
power of rapid diffusibility through the air which be- 
longs to the latter virus : and it is also clearly dis- 
tinguished by its extraordinary tendency to affect a 
number of individuals belonging to the same family, 
even though their exposure to its influence may have 
been very slight. It is clear that original constitution 



DIPHTHERIA. 75 

is a highly predisposing cause of the disease. Less than 
almost any other known epidemic disease does diph- 
theria appear to be influenced by the existence Of sani- 
tary defects in a house or a neighborhood : the most 
that can be said of these influences is that the malady 
probably lurks longest in localities where they are pre- 
sent in a high degree. On this point the elaborate 
researches of Dr. Sanderson (made for the medical de- 
partment of the Privy Council), and of Dr. Greenhow, 
seem to have exhausted the topics of inquiry, with an 
almost entirely negative result. Nor is there any evi- 
dence that destitution has any particular predisposing 
effect, although bodily fatigue, and more especially 
nervous exhaustion from overexcitement of intellect 
or emotions, appear to render both the poor and the 
wealthy liable to the attacks of the disease. But the 
one predisposing cause which outweighs all others — 
even that of hereditary constitution — is age. Like 
scarlatina, it is eminently a disease of children ; and it 
rarely occurs twice. But the adult who takes it is far 
more liable to suffer severely than the adult who con- 
tracts scarlatina, except, indeed, when the latter disease 
attacks women at the time of confinement, when it is 
excessively fatal. 

The early symptoms of diphtheria are often obscure, 
and unfortunately the progress of the malady is usually 
so rapid that serious results may ensue from ignorance 
on the part of the patient's friends as to the nature of 
his complaint The introductory fever is usually slight, 
and the symptoms which first arouse attention are the 
occurrence of glandular swelling about the neck (under- 
neath the jaw), and difficulty of swallowing ; together 
with a very marked sense of depression and great 
drowsiness. In about twenty- four hours, more or less, 



T6 NOTES ON EPIDEMICS. 

from the first occurrence of uneasiness in the throat, the 
tonsils and back of the throat have become red or pur- 
ple, and much swollen, and soon after this a peculiar ap- 
pearance is observed, viz., the presence of a thick layer of 
whitish or yellowish membranous matter coating the 
affected parts at the back of the mouth. It is of great 
importance, however, that medical assistance should, if 
possible, be called before the affection has arrived at 
this latter stage ; and it is a good rule, especially when 
diphtheria is known to be prevalent, that no case of 
sore-throat, attended with great depression and diffi- 
culty of swallowing, should be left without medical 
inspection. Sometimes the disease affects the wind- 
pipe, from the first, more powerfully than the throat, 
though, as a rule, the order of events is opposite to this. 
When the windpipe becomes affected there is more or 
less embarrassment of breathing ; at the same time the 
difficulty of swallowing becomes more and more pro- 
nounced. The obstruction of breathing is always a 
most formidable sign when it comes on rapidly under 
circumstances which make the existence of diphtheria 
probable, or even possible ; for in this disease the affec- 
tion of the windpipe which interferes with free respira- 
tion consists in the exudation of a membranous coating 
on the inner surface of the air-tube, exactly similar to 
what is seen on the tonsils and the back of the throat ; 
and death very often results from the mechanical stop- 
page of the tube by the membranous substance : the 
patient becomes suffocated, in fact. 

Both scarlet fever and diphtheria are formidable, not 
only on account of the great mortality which they cause, 
but from the dangerous effects which they often leave 
behind them in the general constitution. The former 
is very liable to be followed by kidney disease and 



MEASLES. 11 

dropsy, by abscesses of the tympanum and consequent 
deafness, or by tubercular disease; the latter is dis- 
tinguished among all epidemic diseases by a tendency 
to produce some peculiar forms of paralysis. 

Measles. — Of the causes of measles there is little to 
be said which can immediately benefit the public. Our 
knowledge of its origin and propagation is almost 
limited to the facts that it is excessively contagious, 
though not so much so as scarlatina ; that it is very 
fatal to children, especially in crowded towns; and that 
the poison is diffusible through the atmosphere, so that 
the only chance of mitigating its activity lies in using 
the freest ventilation. Like scarlatina, it presents no 
features, in the present day, which give us the right to 
assume an origin de novo; and insanitary conditions, 
with the exception of defective ventilation, exercise 
only a moderate influence on its progress or fatality. 

We say " with the exception of defective ventila- 
tion," and this is important, for great aggravation of 
the virulence of the contagion of measles may be pro- 
duced by this agency. We can hardly illustrate this 
better than by relating an instance which came under 
our notice a few months since. In the workhouse of 
St. Martin's-in-the-Fields (an old, dingy, and unwhole- 
some building, jammed in behind the National Gallery) 
the nurseiy, in which a number of young children are 
kept by night and day, is extremely ill- ventilated and 
overcrowded, and its atmosphere is habitually foul ; at 
least this was the state of things at the time of our 
visits, in June and August, 1865. We learned that 
some months previously a woman accidentally came 
into this apartment, bearing with her the infection of 
measles ; the result was a most disastrous outbreak of 



18 NOTES ON EPIDEMICS. 

the disease, in which nearly all the children were at- 
tacked, and eight, nearly half of those who sickened, 
lost their lives ; the contagiousness of the disease was 
most virulent. 

The early symptoms of measles are usually distinc- 
tive, if carefully observed ; but where attention has not 
been called to the patient's complaints at an early stage 
there is sometimes considerable difficulty in deciding as 
to the nature of the disease, since the eruption often 
presents resemblances to that of scarlatina. 

A typical case of measles commences, about a fort- 
night after exposure to infection, with chilliness or 
actual shivering, and with severe symptoms of cold in 
the head, the sneezing being usually violent, and the 
eyes being red and watery. The thermometer applied 
to the armpit detects the fact that the temperature is 
rapidly rising ; by about the end of the fourth day, in- 
clusive, it stands, on the average, at 106°; it is now 
that the eruption makes its appearance; the tempera- 
ture still goes on rising for about twenty-four hours 
longer, and very commonly reaches the great height of 
109°, from which point it steadily and rapidly falls 
again. The eruption appears (according to Dr. Aitken) 
in three successive crops at intervals of about twenty- 
four hours ; the first crop appears on the face, neck, and 
arms, the second on the trunk, the third on the lower 
extremities. The spots are at first small, like flea-bites, 
but they afterward run together and form patches, 
which are often of a crescentic form; they are most 
thickly scattered on the face, back, and loins ; their 
color is generally of a deep raspberry hue ; they disap- 
pear on pressure, and return when this is removed. 
This is the typical character of the eruption. But it 
may, on the other hand, vary in the direction of re- 



SMALL-POX. 1 9 

semblance to scarlatina, the spots being very numerous, 
small, and distinct from each other, and of a bright-red 
color, so that their general appearance resembles that of 
the blush of the scarlatinal eruption. And on the other 
hand, the spots sometimes assume the character of little 
pimples, which may even have a watery head; in this 
case great doubt may be felt whether the disease is 
not small-pox. Fortunately, there will be no need 
for the patient or his friends to decide any such doubt- 
ful points, for the indications of the thermometer will 
be such as to indicate that the case demands medical 
advice. 

Small-pox. — At this point we think proper to intro- 
duce a few words, of description only, with respect to 
small-pox. As already stated, we have no intention to 
discuss the pathology of the disease, because it has 
been removed, by the invention of vaccination, from the 
list of those diseases which cause a very large mor- 
tality, and its importance to the public is thus dimin- 
ished. But so long as centers of infection are left in 
existence by the imperfect carrying out of vaccination, 
there will be occasional outbreaks of the disease, not 
merely among the poor, but even among the wealthy 
classes ; we think it necessary, therefore, to describe the 
premonitory symptoms, which call for the immediate 
adoption of precautions. After the patient has received 
the infection, there is a period of latency or incubation, 
varying from ten to sixteen days, and then the symp- 
toms commence with a shivering fit, followed by in- 
tense pain in the limbs and especially in the back, and 
in nearly every case by severe vomiting. There is 
severe headache and drowsiness, and sometimes even 
insensibility. Febrile heat is developed, and contin- 



80 NOTES ON EPIDEMICS. 

uously rises, till about the evening of the fourth day, 
when the eruption makes its appearance ; at this mo- 
ment the thermometer stands, on the average, at 104°. 
The eruption consists of pimples scattered most thickly 
on the face, and when the disease is natural in type, the 
appearance is so characteristic that it is not likely to be 
mistaken. But when, as now and then happens, the 
infection of small-pox attacks a person already partly 
protected by an imperfect or too long past vaccination, 
the character of the rash, and indeed the whole course 
of the disease, may be modified in such a way as to 
puzzle even the most skilled physicians. In any case 
the appearance of the eruption is followed by .a remark- 
able and steady fall of the temperature, which continues 
without intermission during the next clay or two, and 
is accompanied by a great alleviation of the oppression 
under which the patient labored in the pre-emption 
stage. During the first twenty-four hours from the 
commencement of symptoms, there w r ould be always a 
doubt between small-pox and scarlatina, but the occur- 
rence or non-occurrence of the scarlatina rash at about 
the end of that time would, in most cases, settle the 
matter as between these two diseases. Even then 
there might be a doubt, up to the moment of the erup- 
tion, between small-pox and typhus, were it not for the 
thermometer, which in the former disease gives no in- 
dication of the remarkable daily rises and falls of tem- 
perature which occur during the pre-eruption stage of 
typhus, and which have been already described. 

Whooping-cough. — Most of the remarks which we 
made with reference to the state of our knowledge of 
the pathology of measles might be used in speaking of 
whooping-cough, save that the latter disease is far 



WHOOPING-COUGH. 81 

more commonly known to occur in isolated, so-called 
"sporadic," groups of cases. 

Whooping-cough stands in a remarkable position 
among epidemic diseases. It is plainly contagious in 
a high degree ; and its course, though very long, is 
divisible into three tolerably distinct stages. But the 
first stage (which should be that of initial fever) is at- 
tended, usually, with very little real elevation of the 
bodily temperature. We have repeatedly examined 
patients with the thermometer, and have never found 
the temperature to exceed 100°, unless the case was 
complicated with bronchitis or pneumonia. There is 
commonly, however, some little catarrh, and some slight 
oppression of breathing, during the first stage. The 
cough is from the first noisy, and occurs in long fits, 
during the interval of which the patient is quiet. The 
commencement of the second stage is marked by the 
development of the characteristic "whoop;" a sound 
which it is impossible to describe, but which, once 
heard, is easily recognized again. But it is important 
to discover the existence of the disease in its initial 
stage, so that measures may be adopted for avoiding 
the spread of the malady to other persons. The only 
symptom which can be of use for this purpose is the 
paroxysmal nature of the cough, taken together with 
the age of the patient, and the fact that he has never 
suffered from whooping-cough before (a second attack 
of the disease being rare), and the prevalence of the 
complaint in the neighborhood at the time. Whooping- 
cough is usually regarded as a trifling disease, and 
parents think with little alarm of the probability of its 
spreading from one member of their family to the 
others. It is, however, of real consequence that weakly 
children should be spared if possible from this malady ; 



82 NOTES ON EPIDEMICS. 

for its influence on delicate young persons, especially 
those who possess an hereditary taint of consumption, 
is often most injurious. It is also highly important that 
infants who are going through teething should be spared 
an infliction of the disease. Dentition is always a try- 
ing process for the nervous system ; it is a familiar fact 
that convulsions are very apt to occur during its prog- 
ress. Now whooping-cough is caused by a poison 
which operates with especial force upon the nervous 
centers, and, indeed, the specific "whoop" is the con- 
sequence of a convulsive affection of the muscles of the 
larynx arising from nervous irritation ; it is easy, there- 
fore, to see how likely this complaint is to aggravate 
any existing tendency to convulsions. For the above 
reasons it is highly important that all delicate children 
and all young infants should be separated from infected 
subjects as soon as the latter can be proved to suffer 
from this disease. Where it is not possible to prevent 
the healthy living in the same house with the sick, it 
should be made an absolute rule that they should not 
sleep together, nor play together, and especially that 
they should not kiss each other, as the breath unques- 
tionably conveys the poison. 

Measles and whooping-cough, of whose origin we 
know so little, and against which we have but few pre- 
ventive resources, are constantly with us, and they 
respectively killed 18,256 and 26,982 persons, in the 
thirteen years from 1852 to 1864 (inclusive), in London 
alone. So large a mortality could hardly fail to pro- 
duce great terror, but for one circumstance, which it is 
sad to think should have so deadening an influence on 
public feeling ; we mean the fact that the immense 
majority of these deaths are those of young children. 
It is a melancholy sign of the effects of that ever- 



INFLUENZA. 83 

growing curse of England — the overpopulation of the 
land — when we see the untimely fate of these children 
attracting so little notice. It is certain, however, that 
the medical profession does not share this apathy ; on 
the contrary, the very obscurity which surrounds these 
diseases, and some others of which we have spoken, 
renders them the objects of intense and eager curiosity ; 
and we feel little doubt that something will be elicited 
before long which will throw light upon the matter. 

Influenza. — Influenza is a disease which has a greater 
importance than might be supposed, from the small 
number of deaths (only 1168) which have been men- 
tioned as occurring from it during a period of thirteen 
years. In truth, this malady, though it has probably 
occurred at intervals from the earliest times, has never 
appeared in this country in a wide-spread epidemic 
form since the year 1847, but on that occasion it at- 
tacked no less than 250,000 persons in London alone; 
the mortality was something appalling, but it fell chiefly 
on adults, and especially on the aged. Thus, while the 
average mortality in childhood was raised 83 per cent, 
by the epidemic, that of adults was raised 104 per cent., 
and that of aged persons 24*7 per cent. The causes of 
the epidemic influence are not known with any ap- 
proach to certainty, the only theory on the subject 
which has any weight of facts to support it being the 
hypothesis of propagation by fungoid germs : but this 
is at present a mere speculation. In its power of sweep- 
ing suddenly over a wide space of country, and infect- 
ing an immense number of individuals, influenza stands 
almost, if not quite, at the head of all the zymotic class. 

No word is more commonly and mischievously per- 
verted in its popular application than "Influenza." 



84 NOTES ON EPIDEMICS. 

The term is vaguely applied to every severe cold which 
is attended with a good deal of depression ; but, in 
truth, the genuine influenza is a specific febrile disease, 
which differs widely from common catarrh in the man- 
ner of its attack, the course which it runs, and the 
severity of the impression which it makes on the sys- 
tem. True influenza is both epidemic and endemic, — 
that is to say, it prevails occasionally in a widely ex- 
tended form, and, frequently, in limited local outbreaks. 
It is not specifically a disease of winter weather, though 
the influence of a low temperature undoubtedly pre- 
disposes individuals to take the disease when it is pre- 
valent. Its attack is characterized by the occurrence of 
shivering, pains in the limbs, and very distressing head- 
ache, chiefly felt over the eyes, together with severe 
symptoms of cold in the head, and cough, attended 
usually with much expectoration. More or less febrile 
excitement prevails for three or four days, and com- 
monly ends in an attack of diarrhoea ; but after the 
fever has passed away an extraordinary depression of 
bodily and mental energies remains ; and in the case of 
persons predisposed to consumption or other constitu- 
tional diseases it not unfrequently happens that the 
latent morbid tendency is evoked, and the patient falls 
into confirmed ill health. It is this remarkable prostra- 
tion, and the tendency to the development of constitu- 
tional diseases (especially of the tuberculous class) 
which most distinctly separates true influenza from 
common catarrh. The popular notion that common 
colds, if neglected, frequently end in consumption is 
completely erroneous ; for it has been proved, on the 
one hand, that consumptive patients are not, in the 
majority of instances, susceptible to attacks of catarrh; 
and, on the other hand, extended observation shows 



YELLOW FEVER. 85 

that symptoms of consumptive lung disease are almost 
never evoked by simple catarrh. But influenza, like 
typhoid fever, leaves a disastrous impression on the 
whole bodily nutrition ; and it too often happens that 
this is sufficient to call forth hereditary tendencies to 
tubercle of the lungs which might otherwise have lain 
dormant during a lifetime. It follows that symptoms 
of severe catarrh, occurring at a time when influenza is 
prevalent, ought not to be treated with the indifference 
which we are accustomed to feel for a common cold, 
but should be looked upon as demanding immediate 
medical assistance. For the same reason it is most im- 
portant that the dangers attending infection should be 
recognized, and that, on the occurrence of influenza in 
a household, those members of it who have ever shown 
a tendency to delicate health, and especially to con- 
sumption, should be promptly removed to some other 
neighborhood. 

In concluding our notice of British epidemics we 
cannot pass without notice one disease which, though 
it has never planted itself to any extent in this country, 
possesses a peculiar interest just now, in consequence 
of a limited invasion of it which recently occurred. 
We refer to yellow fever, which a few months since 
was brought to Swansea by the ship Hecla, and in- 
fected a limited number of the inhabitants of that 
town. 

Yellow Fever. — Yellow fever is a disease of tropical 
origin, and is developed in by far the greatest extent in 
the West Indian Archipelago and on the coast of the 
Gulf of Mexico ; and it is now proved to require, for its 
development to any great degree, the presence of a very 



8b NOTES ON EPIDEMICS. 

high temperature. Nevertheless, it may be carried to 
European countries by ships ; and this has repeatedly 
taken place ; but on such occasions it takes no serious 
hold upon the inhabitants unless a high temperature be 
present. The disease derives its name of yellow fever 
from the occurrence of a peculiar jaundice of the skin, 
and its Mexican name of vomito, from the fact that 
matters are vomited which consist largely of dark 
blood. The presence of these symptoms has long 
caused it to be considered as one of the malarious 
fevers ; but observation has of late convinced many of 
the best observers that it is in reality a specifically 
separate malady, not dependent specially upon malaria 
at all. In truth, it is difficult to read carefully the his- 
tories of West Indian epidemics of yellow fever without 
being tempted to believe that the disease has strong 
affinities with our English typhus ; and the peculiar 
symptoms (jaundice and black vomit) of which so much 
has been made, are in truth phenomena which are not 
unfrequently witnessed in typhus and in relapsing fever 
in Britain. So often has this been the case that one 
can hardly avoid thinking that, were these latter fevers \ 
transplanted to the peculiar tropical regions which have 
been mentioned, they would develop these features with 
constancy, instead of occasionally, and would then be 
indistinguishable from true yellow fever.* Yery much 
of the specific evidence as to the manner in which the 
contagion of yellow fever begins and spreads in ships, 
seems to point in the same direction. And, finally, the 
very interesting Report of Dr. G. Buchanan, made by 



* In this country, some parts of which are periodically subject to 
yellow fever, the distinctness of this disease and typhus is clearly 
recognized. — Am. Ed. 



YELLOW FEVER. 81 

the desire of the medical officer of the Privy Council, 
on the recent events at Swansea, appears to us to 
render the likeness of yellow fever to typhus very strik- 
ing. It is remarked, both by Dr. Buchanan and by Dr. 
Macdonald, that the poison of yellow fever adheres with 
great obstinacy to places; and Dr. Buchanan shows, in 
a very satisfactory manner, that at Swansea the ship 
was the infected place which really caused the limited 
spread of the fever which took place. Around the ves- 
sel, as a center, the fever radiated for a short distance 
only, and the infected persons seem in every case to 
have been brought directly or indirectly within the 
local influence. Now this adherence of virulent con- 
tagion to a ship, is excessively like the infection which 
clings to certain houses in London where typhus has 
repeatedly occurred ; and when we learn that on the 
removal of the ship from Swansea harbor no more 
cases of yellow fever occurred, the likeness is rendered 
still more striking. 

It is right to state, however, that this is only our in- 
dividual opinion, and that Dr. Buchanan himself draws 
a different inference from the facts which have led us 
to this conclusion. He remarks that the several per- 
sons who seem to have been poisoned by the infected 
ship did not spread the disease around them in the 
places where they lay sick, and that this is contrary to 
our experience of the more contagious diseases, such as 
typhus, small-pox, etc. For our own part we are in- 
clined to trace this comparative non-communicability of 
the disease between human beings to the fact that yel- 
low fever is a specific variety of typhus which requires 
a tropical heat for the full development of its mischiev- 
ous activity: and also in great part to the speedy and 
decisive measures which were taken by the authorities 



88 NOTES ON EPIDEMICS. 

for the disinfection of every house which a yellow fever 
patient had inhabited. An examination of the very 
careful and elaborate summary of the cases which actu- 
ally occurred, which Dr. Buchanan gives in an appendix, 
makes it clear that several of the sufferers were in- 
fected not directly from the ship, but from some person 
who had himself derived the poison from the vessel, 
and with whom they had been in close communication. 
Now bearing in mind what has been said of the special 
character of typhus contagion — how intensely active it 
is within a narrow area around the infected person, and 
how easily it is prevented, by proper precautionary 
measures, from spreading beyond the limits of a room 
or award — there is nothing surprising, we think, in the 
fact that the spread of infection was so readily arrested. 
The facts do, indeed, warrant a strong inference that 
the poison had not that highly volatile and diffusible 
character which belongs to the virus of small-pox or 
scarlatina, but they do not seem to establish any incom- 
patibility between it and the poison of typhus ; rather 
the reverse, as it seems to us. And we have reason to 
know that one of the highest authorities on epidemic 
diseases — Dr. Murchison — inclines strongly to a belief 
in the existence of a close relationship between yellow 
fever and typhus. 

In concluding this short sketch of the epidemic dis- 
eases which are of prime interest to the inhabitants of 
the British Islands, we must endeavor to sum up those 
considerations which are of practical value to the public 
and to statesmen. The following appear to be the chief 
suggestions toward the prevention and mitigation of 
epidemic diseases which result from the latest teach- 
ings of medical science. 



CONCLUDING REMARKS, 89 

1. As regards the epidemic fevers which, in their 
severe forms at least, result mainly from the previous 
ill effects of privation and distress, a lesson of enormous 
value has been taught us by the history of the Cotton 
Famine. The very conditions were here presented 
under which relapsing fever and typhus have time 
after time been generated ; and yet, thanks to the 
timely relief afforded by the supply of food and cloth- 
ing (or money to buy them), and the scarcely less 
precious moral influence of sympathy, the afflicted pop- 
ulations escaped with but a trifling visitation of this 
kind of diseases. ~No sensible person can fail to see in 
this example a warning to the legislature that, by wise 
enactments giving a power of exceptional extension to 
the administration of Poor Law relief, they have the 
opportunity of intervening in the very earliest stages of 
any threatening mischief of this kind, with the effect of 
preventing a prodigious loss of lives. 

2. Of all the measures which are adapted to check 
the progress and spread of contagious diseases, there 
are none which are comparable in value to the early 
isolation of the patients, and their treatment in apart- 
ments, the ventilation of which is exceptionally free, 
while as little as possible of woolen or other stuffs 
which may retain the poison of the disease is employed 
in the way of furniture. In the case of scarlatina and 
small-pox it is necessary not merely to do this, but to 
remove all the non-infected persons (who are not " pro- 
tected" by a previous attack) from the house. It is 
accordingly of the greatest moment that the premoni- 
tory symptoms of all contagious diseases should be 
known to the public themselves : this is not a matter 
which the medical profession wishes, or would think it 
right, to make any mystery about ; on the contrary, 

8* 



90 NOTES ON EPIDEMICS. 

medical men would gladly see all persons, especially all 
mothers and heads of households generally, in posses- 
sion of a sound working acquaintance with the value of 
premonitory indications, and especially of such infalli- 
ble criteria of the severity of threatened mischief as are 
supplied by the indications of the thermometer. It 
would also be highly desirable that the study of really 
good pictorial representations of the characteristic erup- 
tions of the contagious fevers should become general 
among women of every class : there is no fear that the 
public would be terrorized by this, on the contrary, 
many needless alarms which now occur would be 
avoided by a fuller knowledge of this subject than is 
at all commonly possessed by mothers of families ; while 
at the same time many a life would be saved by the 
timely separation of infected persons from their com- 
panions. 

3. With regard to such diseases as depend for their 
propagation on the contamination of air and of drink- 
ing-water by sewage matters, it is certain that the 
means of prevention may be applied, if the legislature 
has any real desire to act earnestly, with the best pros- 
pects of success. It is certain that typhoid fever might 
be exterminated by the compulsory provision of a com- 
plete system of drainage on the one hand, and of pure 
water supply on the other. It is highly probable that 
the same precautions would render anything like a 
severe outbreak of the Asiatic form of cholera impos- 
sible ; and that the severe epidemics of diarrhoaa which 
give such a fatality to the autumn season might be 
extinguished. 

4. The evil influence of overcrowding is assuming 
gigantic proportions, and cannot, without much peril, 
be treated any longer on the do-nothing system. Either 



CONCLUDING REMARKS. 91 

by government interference or by private enterprise, a 
large proportion of the operatives who work in London 
and other great cities ought to be provided with proper 
and wholesome apartments, built in blocks, and fur- 
nished with sanitary appliances, near the scene of their 
labors, or else they should be induced to take suburban 
residences, and arrangements made by which they 
might be transported to their daily work by railways. 
If some system of this kind be not commenced very 
soon, typhus fever, which has already changed from an 
occasional visitor to an accustomed domestic scourge, 
in London, will become more and more rooted in its 
favorite haunts, and may not impossibly take some 
more malignant type, such as that of the Oriental 
plague, of which it is probably a mere modification. 
Nor can any one assume that it will continue in such 
changed circumstances to be a disease almost confined 
to the poor ; on the contrary, it may very probably ex- 
tend its ravages to all classes of the community in our 
crowded cities. 

5. It is intolerable, in view of the facts which have 
been briefly narrated in the present paper, that the 
management of sanitary matters should be any longer 
committed to the vestries, as those bodies are consti- 
tuted at present. Even if we credit them with the 
purest and most disinterested motives, it is impossible, 
with their limited and confused views of scientific ques- 
tions, that they should grapple adequately with prob- 
lems of such deep importance as the reduction of over- 
crowding, the supply of really pure drinking-water, and 
the immediate isolation of cases of infectious disease. 
It is true that they could not be expected to do this 
thoroughly, in any case, until they had received larger 
compulsory powers than Parliament has as yet put into 



92 NOTES ON EPIDEMICS. 

their hands. But the best proof of their incompetency 
for their duties is the very fact that these legal difficul- 
ties remain, and yet no action takes place on the part 
of the vestries, with a view to secure parliamentary 
authority for carrying out the necessary reforms. 

Here we must leave our subject. We have placed 
in the hands of those who have been at pains to read 
this little treatise carefully, a series of facts which point 
to the most urgent duties resting upon all members of 
the community who have the slightest influence in the 
management of local affairs, or the smallest power of 
moving Parliament. It is the simple truth that on the 
rapidity with which we may be able to introduce the 
more important of those sanitary improvements which 
tend to exterminate epidemic diseases, will depend very 
much of the greatness or feebleness of England as a 
nation during the next half century. It will not do to 
flatter ourselves with considerations of the reduced rate 
of mortality that was undoubtedly caused by sanitary 
reform in the flush of its youth, with such a fact under 
our eyes as the localization and steady increase of 
typhus in London, and in many other large towns. 
The influence exerted on the laboring populations of 
crowded towns by the constant presence of such a dis- 
ease as typhus, and by the havoc committed among 
their families by other epidemic diseases, is not merely 
disastrous to life, but highly demoralizing, because it 
originates such a sense of the insecurity of life as tends 
to render the lowest classes more and more reckless, 
and more and more incapable of raising themselves 
from their debased condition. Few are aware to what 
a length we have already gone, in this metropolis, to- 
ward the creation of a " dangerous class " by our neglect 
of the most obvious facts in connection with the growth 



CONCLUDING REMARKS. 93 

and " improvements" of London. Assuredly, if we shut 
our eyes much longer to the dangerous tendencies of 
the present state of things, we, or our immediate suc- 
cessors, will have occasion bitterly to regret our folly. 
But it is not enough to feel these truths, and to attempt 
to carry out their sense, unless we are possessed of a 
fitting organization for the purpose ; and we would take 
this occasion to enforce the urgent necessity which ex- 
ists for the formation of a general State Medical Depart- 
ment, which among its other duties might, by constant 
vigilance and united action, enable the sanitary ques- 
tions which arise out of the rapid growth and altera- 
tions constantly taking place in the various centers of 
population to be settled satisfactorily without loss of 
time. It is our slowness of action which is so peril- 
ous ; and any statesman who would for a moment con- 
sent to postpone the business of making declamations 
for or against reforms of the electoral franchise, and 
devote his talents to the organization of a really author- 
itative medical direction of sanitary reforms, would 
deserve the sincere gratitude of his country. 

It may be well to say a few words, perhaps, on the 
subject of a temporary and immediate expedient which 
has occurred to many as desirable at the present time ; 
we mean the appointment of a commission to investi- 
gate the sanitary state of the kingdom, with a view 
especially to prepare for, and as far as possible miti- 
gate, the expected attack of cholera. We heartily de- 
sire that this scheme may be carried out without loss 
of time ; and we know of only one objection which any 
reasonable man can make to it, viz., that it is one of 
those measures which an ignorant and apathetic public 
is too apt to think definitively and finally curative. By 
all means let us have a commission, composed of the 



94 NOTES ON EPIDEMICS. 

ablest scientific men; but, above all things, let us re- 
member that this ought only to be looked on as a stop- 
gap, and that our preparations and exertions and efforts, 
for the establishment of a permanent sanitary organiza- 
tion of a thoroughly satisfactory kind, ought never for 
a moment to relax. 

One parting word may properly be added on the 
subject of the ''curability" of the epidemic fevers. It 
is important that the public should understand that the 
majority of these diseases have a definite minimum 
duration which nothing can alter, that their natural 
tendency is, on the whole, to a favorable termination, 
and that the best and most enlightened physicians are 
the most firmly convinced that there exists no practica- 
ble means of shortening the natural term of these mala- 
dies. Therefore, when we speak of "cure " by medical 
treatment, we mean no more than this : that the inter- 
ference of a vigilant and skillful physician frequently 
prevents the patient from sinking under the disease 
before it has run its natural course, or averts some of 
those evil consequences which are apt to follow when 
the patient was previously in delicate health or was 
affected with latent tendencies to constitutional disease. 
It is perhaps a matter of doubt whether the erroneous 
popular notions on this point, which attribute to the 
skillful physician the power of cutting short the most 
acute fevers with a few doses of medicine, have not ex- 
ercised as disastrous an effect on medical science as in 
the confidence of patients in their advisers. Uncon- 
sciously and involuntarily medical men have been some- 
times tempted, by the urgent desires of their friends for 
speedy relief to the sufferer and for his immediate 
deliverance from danger, to spend their energy upon 
the weakest, and to neglect the strongest part of the 



CONCLUDING REMARKS. 95 

defense against disease. It can never be too often re- 
peated, that by far the most difficult and scientific por- 
tion of the medical man's task in the treatment of acute 
disease, is the direction of hygienic measures, and above 
all, the apportionment of the proper food, and the exact 
manner in which that food shall be taken; and that 
these are the means by the right employment of which 
the physician saves his patients in ninety-nine out of a 
hundred cases which recover from dangerous attacks of 
epidemic disease. 



THE END. 



